Healthcare Provider Details

I. General information

NPI: 1104943687
Provider Name (Legal Business Name): KENNETH ANTONIO GOURGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15490 SW 230TH ST
MIAMI FL
33170-6900
US

IV. Provider business mailing address

15490 SW 230TH ST
MIAMI FL
33170-6900
US

V. Phone/Fax

Practice location:
  • Phone: 786-326-8512
  • Fax: 305-256-4277
Mailing address:
  • Phone: 786-326-8512
  • Fax: 305-256-4277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberTT 11458
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: