Provider Demographics
NPI:1679750095
Name:GOFORTH, GRETA MAYA (LAC/HHP)
Entity type:Individual
Prefix:MS
First Name:GRETA
Middle Name:MAYA
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:LAC/HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 N VULCAN AVE SPC 71A
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2131
Mailing Address - Country:US
Mailing Address - Phone:760-815-6265
Mailing Address - Fax:
Practice Address - Street 1:187 CALLE MAGDALENA STE 214
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3712
Practice Address - Country:US
Practice Address - Phone:760-815-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2021-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11921171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist