Provider First Line Business Practice Location Address:
112 EAST FOURTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-356-6982
Provider Business Practice Location Address Fax Number:
505-356-3773
Provider Enumeration Date:
11/22/2006