Provider Demographics
NPI:1841589637
Name:GIFFORD, MYRA (LAC)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:
Last Name:GIFFORD
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 1:174 HARBOR OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2846
Mailing Address - Country:US
Mailing Address - Phone:831-334-2585
Mailing Address - Fax:831-454-8670
Practice Address - Street 1:912 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:CA
Practice Address - Zip Code:95018-9648
Practice Address - Country:US
Practice Address - Phone:831-335-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11865171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist