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Individual

JACK D VICK

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
MD

Contact information

Practice address
546 N. 10TH STREET, FORT SUMNER, NM 88119-0349
(575) 355-2414
(575) 355-7894
Mailing address
PO BOX 349, FORT SUMNER, NM 88119-0349
(575) 355-2414
(575) 355-7894

Taxonomy

Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
92371
NM

Other

Enumeration date
10/24/2006
Last updated
05/19/2009
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