Healthcare Provider Details

I. General information

NPI: 1174868863
Provider Name (Legal Business Name): KENNETH RAYMOND GORZEN L.M.T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 LAKE STREET
SOUTH FALLSBURG NY
12779-1093
US

IV. Provider business mailing address

352 LAKE STREET PO BOX 1093
SOUTH FALLSBURG NY
12779-1093
US

V. Phone/Fax

Practice location:
  • Phone: 845-434-5600
  • Fax:
Mailing address:
  • Phone: 845-434-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number015058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: