Provider Demographics
NPI:1073551685
Name:CRANDALL, BENJAMIN DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DALE
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 FRANCONIA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-4426
Mailing Address - Country:US
Mailing Address - Phone:703-719-0900
Mailing Address - Fax:703-719-0748
Practice Address - Street 1:6080 FRANCONIA RD
Practice Address - Street 2:SUITE B
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-4426
Practice Address - Country:US
Practice Address - Phone:703-719-0900
Practice Address - Fax:703-719-0748
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT31271Medicare UPIN
VACR504793Medicare ID - Type Unspecified