Healthcare Provider Details

I. General information

NPI: 1659312668
Provider Name (Legal Business Name): SANDRA LEA SPORE RN DC DABCI DACBN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 W FRONTAGE RD VALLEY RIDGE MALL
STILLWATER MN
55082
US

IV. Provider business mailing address

1530 W FRONTAGE RD VALLEY RIDGE MALL
STILLWATER MN
55082
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:
Title or Position:
Credential:
Phone: