Healthcare Provider Details

I. General information

NPI: 1306218227
Provider Name (Legal Business Name): BENJAMIN VAUGHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6016 LOVERS LN STE 3
PORTAGE MI
49002-3050
US

IV. Provider business mailing address

866 3 MILE RD NW
GRAND RAPIDS MI
49544-8217
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-0934
  • Fax: 269-329-0965
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501017354
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: