Provider Demographics
NPI:1356706972
Name:BEIDEMAN, BENJAMIN FREDERICK
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:FREDERICK
Last Name:BEIDEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 LACEY RD UNIT 749
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-8037
Mailing Address - Country:US
Mailing Address - Phone:732-930-1820
Mailing Address - Fax:
Practice Address - Street 1:610 LACEY RD UNIT 749
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-8037
Practice Address - Country:US
Practice Address - Phone:732-930-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-26
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNOT REQUIRED133NN1002X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education