Provider First Line Business Practice Location Address:
PO BOX 26666
Provider Second Line Business Practice Location Address:
PHS PROVIDER ENROLLMENT
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87125-6666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-923-5362
Provider Business Practice Location Address Fax Number:
505-923-5362
Provider Enumeration Date:
08/11/2005