Provider Demographics
NPI:1356790281
Name:HEREDIA, BENJAMIN JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JAMES
Last Name:HEREDIA
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 1:524 SE 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2428
Mailing Address - Country:US
Mailing Address - Phone:971-544-7058
Mailing Address - Fax:
Practice Address - Street 1:524 SE 14TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2428
Practice Address - Country:US
Practice Address - Phone:971-544-7058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33582111N00000X
OR5922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor