Provider First Line Business Practice Location Address:
200 5TH ST S TRLR 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOCORRO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87801-0200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-322-0969
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2026