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General NPI Number Information
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NPI Number | 1508775792
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Entity Type | Organization
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Legal Business Name | DLK MEDICINE LLC
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Dates
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Enumeration Date | 09/03/2026
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Last Update Date | 09/03/2026
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Provider Practice Location Address
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Address Line | 4457 S FARM ROAD 145
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City | SPRINGFIELD
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State | MO
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Zip | 65810-1414
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Country | US
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Telephone | 417-830-4701
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Fax | 855-807-2451
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Provider Business Mailing Address
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Address Line | 4457 S FARM ROAD 145
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City | SPRINGFIELD
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State | MO
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Zip | 65810-1414
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Country | US
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Telephone | 417-830-4701
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Fax | 855-807-2451
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | DEATRICE KELLOGG
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Credential | MD
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Telephone | 417-803-4701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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