Provider Information for 1639940877
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JACK SAMUEL VALDEZ
Sex: Male
NPI: 1639940877
Last Updated: 2024-01-15
Certification Date: 2024-01-15
Certification Date: 2024-01-15
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1639940877 | ||||||||
| Enumeration Date | 2024-01-15 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 114 BRIDLE TRL PUEBLO, CO 81005-3031 United States Phone: 719-406-1958 | Fax: | ||||||||
| Primary Practice Address | 114 BRIDLE TRL PUEBLO, CO 81005-3031 United States Phone: 719-406-1958 | Fax: | ||||||||
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