Healthcare Provider Details

I. General information

NPI: 1548988835
Provider Name (Legal Business Name): DIABETES CLINICARE & WELLNESS SPRINGFIELD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1649 S ENTERPRISE AVE
SPRINGFIELD MO
65804-1850
US

IV. Provider business mailing address

3125 S BRANDYWINE TRL
SPRINGFIELD MO
65809-4304
US

V. Phone/Fax

Practice location:
  • Phone: 417-771-5266
  • Fax: 417-590-8232
Mailing address:
  • Phone: 417-771-5266
  • Fax: 417-590-8232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICKY TUCKER
Title or Position: MANAGER
Credential:
Phone: 417-413-1351