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General NPI Number Information
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NPI Number | 1548988835
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Entity Type | Organization
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Legal Business Name | DIABETES CLINICARE & WELLNESS SPRINGFIELD LLC
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Dates
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Enumeration Date | 08/22/2022
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Last Update Date | 08/22/2022
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Provider Practice Location Address
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Address Line | 1649 S ENTERPRISE AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65804-1850
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Country | US
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Telephone | 417-771-5266
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Fax | 417-590-8232
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Provider Business Mailing Address
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Address Line | 3125 S BRANDYWINE TRL
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City | SPRINGFIELD
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State | MO
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Zip | 65809-4304
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Country | US
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Telephone | 417-771-5266
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Fax | 417-590-8232
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Authorized Official
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Title or Position | MANAGER
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Name | RICKY TUCKER
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Credential |
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Telephone | 417-413-1351
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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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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