MEDICARE: ERIC SHANE VAUGHN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	R080863742	OK

General Provider Information

NPI Number	:	1184270415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC SHANE VAUGHN

Provider Business Mailing Address
First Line	:	210 ALLEN DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-2010
Country	:	US
Telephone Number	:	580-630-3686
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 ALLEN DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-2010
Country	:	US
Telephone Number	:	580-630-3686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2019
Last Update Date	:	08/13/2019

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Directions to “ ERIC SHANE VAUGHN ” Practice Location

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