Provider Demographics
NPI:1164578811
Name:DIERAUF, BENJAMIN EDWARD (LAC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
Last Name:DIERAUF
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 DEWING AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4252
Mailing Address - Country:US
Mailing Address - Phone:925-297-4785
Mailing Address - Fax:
Practice Address - Street 1:961 DEWING AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4252
Practice Address - Country:US
Practice Address - Phone:925-297-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 4256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist