Healthcare Provider Details

I. General information

NPI: 1144293903
Provider Name (Legal Business Name): JAMES S. ICE D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 A SECOND ST SE
KIRTLAND AFB NM
87117-5522
US

IV. Provider business mailing address

2050 A SECOND ST SE
KIRTLAND AFB NM
87117-5522
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3547
  • Fax:
Mailing address:
  • Phone: 505-846-3547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberO-87
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: