Provider Demographics
NPI:1770204117
Name:LONGEVITY HEALTH AND WELLNESS
Entity type:Organization
Organization Name:LONGEVITY HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-678-0963
Mailing Address - Street 1:8511 COUNTRY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MANITO
Mailing Address - State:IL
Mailing Address - Zip Code:61546-8619
Mailing Address - Country:US
Mailing Address - Phone:309-678-0963
Mailing Address - Fax:
Practice Address - Street 1:3008 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1083
Practice Address - Country:US
Practice Address - Phone:309-678-0963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-05
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty