Provider Demographics
NPI:1174875298
Name:LONGEVITY CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:LONGEVITY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:STICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:254-394-0836
Mailing Address - Street 1:1504 SANDPIPER PL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-9751
Mailing Address - Country:US
Mailing Address - Phone:254-394-0836
Mailing Address - Fax:
Practice Address - Street 1:2447 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:254-394-0836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6888111NN0400X, 111NS0005X, 111NR0400X
CO6891111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty