Provider First Line Business Practice Location Address:
1917 OLD ROUTE 66, EDGEWOOD PLAZA
Provider Second Line Business Practice Location Address:
SUITE D-1
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-286-2020
Provider Business Practice Location Address Fax Number:
505-286-2244
Provider Enumeration Date:
10/21/2005