Provider Demographics
NPI:1215532668
Name:BOURGOIN, BRANDON KYLE (DPT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:KYLE
Last Name:BOURGOIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 IRVING ST APT 201
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-3226
Mailing Address - Country:US
Mailing Address - Phone:207-631-1166
Mailing Address - Fax:
Practice Address - Street 1:65 PORTLAND RD STE 5
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6742
Practice Address - Country:US
Practice Address - Phone:207-985-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5831208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation