Provider First Line Business Practice Location Address:
1500 S AVENUE K
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:
88130-7400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-367-4845
Provider Business Practice Location Address Fax Number:
972-367-3451
Provider Enumeration Date:
06/30/2015