=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285059527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAUGHN PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2014
-----------------------------------------------------
Last Update Date | 03/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1825 LAUREL ST
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-351-9906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1825 LAUREL ST
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | BRANDON PHYSICAL VAUGHN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 803-351-9906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 6367
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------