Healthcare Provider Details

I. General information

NPI: 1265680094
Provider Name (Legal Business Name): JACK V. WATERS, D.C., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 W 21ST ST
CLOVIS NM
88101-4023
US

IV. Provider business mailing address

1833 W 21ST ST
CLOVIS NM
88101-4023
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-8888
  • Fax: 575-763-8891
Mailing address:
  • Phone: 575-763-8888
  • Fax: 575-763-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number989
License Number StateNM

VIII. Authorized Official

Name: DR. JACK V. WATERS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 575-763-8888