Healthcare Provider Details

I. General information

NPI: 1497543029
Provider Name (Legal Business Name): SPORE SOCIETY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

V. Phone/Fax

Practice location:
  • Phone: 786-929-8596
  • Fax:
Mailing address:
  • Phone: 786-929-8596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AIYON SAIID PEOPLES-NEAL
Title or Position: CEO
Credential:
Phone: 786-929-8596