Provider First Line Business Practice Location Address:
308 1/2 N CANAL ST.
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:
575-237-4838
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2025