Provider First Line Business Practice Location Address:
127 E. SUMNER AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SUMNER
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88119-0550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-355-7357
Provider Business Practice Location Address Fax Number:
505-355-7816
Provider Enumeration Date:
05/21/2007