Provider Demographics
NPI:1902049554
Name:BLACK, MIRANDA (LAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BLACK
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 1:228 NW B ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2032
Mailing Address - Country:US
Mailing Address - Phone:541-244-0111
Mailing Address - Fax:
Practice Address - Street 1:228 NW B ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2032
Practice Address - Country:US
Practice Address - Phone:541-244-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01255171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist