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General NPI Number Information
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NPI Number | 1265680094
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Entity Type | Organization
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Legal Business Name | JACK V. WATERS, D.C., P.C.
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Dates
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Enumeration Date | 09/04/2008
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Last Update Date | 12/10/2008
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Provider Practice Location Address
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Address Line | 1833 W 21ST ST
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City | CLOVIS
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State | NM
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Zip | 88101-4023
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Country | US
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Telephone | 575-763-8888
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Fax | 575-763-8891
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Provider Business Mailing Address
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Address Line | 1833 W 21ST ST
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City | CLOVIS
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State | NM
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Zip | 88101-4023
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Country | US
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Telephone | 575-763-8888
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Fax | 575-763-8891
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACK V. WATERS
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Credential | D.C.
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Telephone | 575-763-8888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 989
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License Number State | NM
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