Provider Demographics
NPI:1104943687
Name:GOURGUE, KENNETH ANTONIO
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANTONIO
Last Name:GOURGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15490 SW 230TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-6900
Mailing Address - Country:US
Mailing Address - Phone:786-326-8512
Mailing Address - Fax:305-256-4277
Practice Address - Street 1:15490 SW 230TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-6900
Practice Address - Country:US
Practice Address - Phone:786-326-8512
Practice Address - Fax:305-256-4277
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT 11458227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified