Provider First Line Business Practice Location Address:
112 E 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88130-6305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-356-6982
Provider Business Practice Location Address Fax Number:
505-356-3773
Provider Enumeration Date:
10/03/2007