Provider First Line Business Practice Location Address:
18 COUGAR ROAD
Provider Second Line Business Practice Location Address:
SAN FELIPE BEHAVIORAL HEALTH PROGRAM
Provider Business Practice Location Address City Name:
SAN FELIPE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-771-9956
Provider Business Practice Location Address Fax Number:
505-867-6166
Provider Enumeration Date:
12/13/2010