Healthcare Provider Details

I. General information

NPI: 1306941406
Provider Name (Legal Business Name): WELLNESS & LONGEVITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 FRONTAGE RD W VALLEY RIDGE MALL
STILLWATER MN
55082-2102
US

IV. Provider business mailing address

1530 FRONTAGE RD W VALLEY RIDGE MALL
STILLWATER MN
55082-2102
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-1013
  • Fax: 651-439-3465
Mailing address:
  • Phone: 651-439-1013
  • Fax: 651-439-3465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2810
License Number StateMN

VIII. Authorized Official

Name: DR. SANDRA LEA SPORE
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 651-439-1013