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General NPI Number Information
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NPI Number | 1306941406
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Entity Type | Organization
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Legal Business Name | WELLNESS & LONGEVITY CENTER
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1530 FRONTAGE RD W VALLEY RIDGE MALL
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City | STILLWATER
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State | MN
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Zip | 55082-2102
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Country | US
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Telephone | 651-439-1013
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Fax | 651-439-3465
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Provider Business Mailing Address
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Address Line | 1530 FRONTAGE RD W VALLEY RIDGE MALL
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City | STILLWATER
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State | MN
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Zip | 55082-2102
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Country | US
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Telephone | 651-439-1013
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Fax | 651-439-3465
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. SANDRA LEA SPORE
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Credential | DC
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Telephone | 651-439-1013
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2810
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License Number State | MN
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