Provider Demographics
NPI:1811303027
Name:BOUFFARD, ELIZABETH (LAC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BOUFFARD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3543
Mailing Address - Country:US
Mailing Address - Phone:510-926-9340
Mailing Address - Fax:
Practice Address - Street 1:3515 GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2037
Practice Address - Country:US
Practice Address - Phone:510-926-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16088171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist