Provider Demographics
NPI:1306941406
Name:WELLNESS & LONGEVITY CENTER
Entity type:Organization
Organization Name:WELLNESS & LONGEVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:SPORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-439-1013
Mailing Address - Street 1:1530 FRONTAGE RD W
Mailing Address - Street 2:VALLEY RIDGE MALL
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2102
Mailing Address - Country:US
Mailing Address - Phone:651-439-1013
Mailing Address - Fax:651-439-3465
Practice Address - Street 1:1530 FRONTAGE RD W
Practice Address - Street 2:VALLEY RIDGE MALL
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-2102
Practice Address - Country:US
Practice Address - Phone:651-439-1013
Practice Address - Fax:651-439-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty