Provider First Line Business Practice Location Address:
128 SOUTH CANAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-628-0503
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2006