Healthcare Provider Details

I. General information

NPI: 1316879901
Provider Name (Legal Business Name): TRAVIS JAMES VAUGHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2026
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 WHISKEY RD
RIDGE NY
11961-8352
US

IV. Provider business mailing address

78 BIRCHWOOD RD
CORAM NY
11727-3680
US

V. Phone/Fax

Practice location:
  • Phone: 631-821-8090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: