=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770204117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONGEVITY HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2022
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3008 W WILLOW KNOLLS DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61614-1083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-678-0963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8511 COUNTRY VIEW DR
-----------------------------------------------------
City | MANITO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61546-8619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-678-0963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. BRANDIE LONG
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 309-678-0963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------