Provider Demographics
NPI:1558933044
Name:DIEDRICK, BENJAMIN M (DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:DIEDRICK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7147 VISTA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-9317
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9223
Practice Address - Street 1:5950 UNIVERSITY AVE STE 285
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8236
Practice Address - Country:US
Practice Address - Phone:515-875-9706
Practice Address - Fax:515-875-9707
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16274225100000X
IA109237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist