Provider Demographics
NPI:1285966598
Name:GOUGH, KENNETH ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:GOUGH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 N FIVE MILE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5234
Mailing Address - Country:US
Mailing Address - Phone:208-324-8484
Mailing Address - Fax:208-321-5084
Practice Address - Street 1:3040 N FIVE MILE RD
Practice Address - Street 2:SUITE C
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5234
Practice Address - Country:US
Practice Address - Phone:208-324-8484
Practice Address - Fax:208-321-5084
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3994111N00000X
IDCHIA-1501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor