Provider First Line Business Practice Location Address:
612 N 13TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARTESIA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88210-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-736-8394
Provider Business Practice Location Address Fax Number:
575-736-8468
Provider Enumeration Date:
03/28/2026