Provider First Line Business Practice Location Address:
214 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCUMCARI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88401-2223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-461-6080
Provider Business Practice Location Address Fax Number:
505-461-4802
Provider Enumeration Date:
10/03/2006