Healthcare Provider Details

I. General information

NPI: 1972285682
Provider Name (Legal Business Name): MARK WILLIAM VAUGHN CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 NW GREENWOOD AVE
BEND OR
97703-2078
US

IV. Provider business mailing address

1337 SW BOARDWALK LN
BEND OR
97702-3788
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-4293
  • Fax:
Mailing address:
  • Phone: 541-630-2458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-23-3290
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number23-CRM-2206
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: