MEDICARE: VAUGHN ALAN CAVENDER IDMT

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1194711127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAUGHN ALAN CAVENDER IDMT

Provider Business Mailing Address
First Line	:	360 DOWNS DR
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-7329
Country	:	US
Telephone Number	:	801-612-2262
Fax Number	:

Provider Business Practice Location Address
First Line	:	7302 WARDLEIGH RD
Second Line	:
City	:	HILL AFB
State	:	UT
Zip	:	84056-5223
Country	:	US
Telephone Number	:	801-586-1625
Fax Number	:	801-777-1521

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

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	07/08/2007

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