Healthcare Provider Details

I. General information

NPI: 1356706972
Provider Name (Legal Business Name): MR. BENJAMIN FREDERICK BEIDEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2015
Last Update Date: 10/27/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 LACEY RD UNIT 749
FORKED RIVER NJ
08731-8037
US

IV. Provider business mailing address

610 LACEY RD UNIT 749
FORKED RIVER NJ
08731-8037
US

V. Phone/Fax

Practice location:
  • Phone: 732-930-1820
  • Fax:
Mailing address:
  • Phone: 732-930-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberNOT REQUIRED
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNOT REQUIRED
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: