Provider Demographics
NPI:1265680094
Name:JACK V. WATERS, D.C., P.C.
Entity type:Organization
Organization Name:JACK V. WATERS, D.C., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:V
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:575-763-8888
Mailing Address - Street 1:1833 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4023
Mailing Address - Country:US
Mailing Address - Phone:575-763-8888
Mailing Address - Fax:575-763-8891
Practice Address - Street 1:1833 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4023
Practice Address - Country:US
Practice Address - Phone:575-763-8888
Practice Address - Fax:575-763-8891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM989261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMB2095Medicare PIN