Provider Demographics
NPI:1548988835
Name:DIABETES CLINICARE & WELLNESS SPRINGFIELD LLC
Entity type:Organization
Organization Name:DIABETES CLINICARE & WELLNESS SPRINGFIELD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-413-1351
Mailing Address - Street 1:3125 S BRANDYWINE TRL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-4304
Mailing Address - Country:US
Mailing Address - Phone:417-771-5266
Mailing Address - Fax:417-590-8232
Practice Address - Street 1:1649 S ENTERPRISE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1850
Practice Address - Country:US
Practice Address - Phone:417-771-5266
Practice Address - Fax:417-590-8232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty