Healthcare Provider Details

I. General information

NPI: 1982796827
Provider Name (Legal Business Name): KEITH K PUGH RPSGT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 ONTARIO ST
JACKSONVILLE FL
32254-2073
US

IV. Provider business mailing address

1015 ONTARIO ST
JACKSONVILLE FL
32254-2073
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-6606
  • Fax:
Mailing address:
  • Phone: 904-387-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number5281
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: