Healthcare Provider Details

I. General information

NPI: 1043430473
Provider Name (Legal Business Name): MARY F. LYELL L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 7TH AVE
SANTA CRUZ CA
95062-4668
US

IV. Provider business mailing address

231 YOUNGLOVE AVE
SANTA CRUZ CA
95060-5347
US

V. Phone/Fax

Practice location:
  • Phone: 831-476-8211
  • Fax:
Mailing address:
  • Phone: 831-325-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 9071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: