Provider Demographics
NPI:1013240563
Name:LOSACK, VINCENT JOHN (LMT)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:JOHN
Last Name:LOSACK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 CORRALES RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8754
Mailing Address - Country:US
Mailing Address - Phone:505-269-3263
Mailing Address - Fax:
Practice Address - Street 1:5606 CORRALES RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8754
Practice Address - Country:US
Practice Address - Phone:505-269-3263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6405174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist