Provider Demographics
NPI:1982750378
Name:GRUNDE, BENJAMIN (LMT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:GRUNDE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 CALYPSO CT
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1594
Mailing Address - Country:US
Mailing Address - Phone:541-821-6550
Mailing Address - Fax:
Practice Address - Street 1:1230 CALYPSO CT STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1594
Practice Address - Country:US
Practice Address - Phone:541-821-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 174H00000X
OR9273174400000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No171400000XOther Service ProvidersHealth & Wellness Coach
No174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator