MEDICARE: BEN TA LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	19550	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19550	OTHER	CA	CALIFORNIA BOARD OF ACUPUNCTURE

General Provider Information

NPI Number	:	1457061152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEN TA LAC

Provider Business Mailing Address
First Line	:	2642 VEGAS AVE
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-6418
Country	:	US
Telephone Number	:	925-216-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	2642 VEGAS AVE
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-6418
Country	:	US
Telephone Number	:	925-216-4838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2022
Last Update Date	:	12/05/2022

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Directions to “ BEN TA LAC” Practice Location

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