Provider First Line Business Practice Location Address: 
408 S. CANYON
    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: 
505-234-3300
    Provider Business Practice Location Address Fax Number: 
505-234-3367
    Provider Enumeration Date: 
06/01/2007