Provider First Line Business Practice Location Address:
1107 SOUTH 11TH 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-461-4344
Provider Business Practice Location Address Fax Number:
505-461-8033
Provider Enumeration Date:
11/17/2006