Healthcare Provider Details

I. General information

NPI: 1164142477
Provider Name (Legal Business Name): BENJAMIN IWAN CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 PALLADIUM LN
LADERA RANCH CA
92694-1201
US

IV. Provider business mailing address

31 PALLADIUM LN
LADERA RANCH CA
92694-1201
US

V. Phone/Fax

Practice location:
  • Phone: 612-384-5889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number91250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: