Healthcare Provider Details

I. General information

NPI: 1891520755
Provider Name (Legal Business Name): SPENCE SPECIALTIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 ETNA ST STE 55
SAINT PAUL MN
55106-5848
US

IV. Provider business mailing address

4365 OAKMEDE LN
SAINT PAUL MN
55110-7606
US

V. Phone/Fax

Practice location:
  • Phone: 651-756-8561
  • Fax:
Mailing address:
  • Phone: 651-402-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: MICHAELENE ROSE COLESTOCK
Title or Position: FOUNDER
Credential: MA LADC LPCC
Phone: 651-402-4055