# LONGEVITY CHIROPRACTIC, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174875298
- **Authorized official:** DR. DEREK WADE STICKLER D.C. (OWNER/MANAGER)
- **Authorized official phone:** (254) 394-0836

## Contact information

- **Practice address:** 2447 S PRAIRIE AVE, PUEBLO, CO 81005
- **Practice address phone:** (254) 394-0836
- **Mailing address:** 1504 SANDPIPER PL, PUEBLO, CO 81006-9751
- **Mailing address phone:** (254) 394-0836

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111NN0400X | Neurology Chiropractor | 6888 | CO | — |
| 111NP0017X | Pediatric Chiropractor | 6891 | CO | — |
| 111NR0400X | Rehabilitation Chiropractor | 6888 | CO | Yes |
| 111NS0005X | Sports Physician Chiropractor | 6888 | CO | — |

## Other

- **Enumeration date:** 10/12/2012
- **Last updated:** 10/04/2019