Provider First Line Business Practice Location Address:
201 S KNOXVILLE 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:
88130-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-356-7015
Provider Business Practice Location Address Fax Number:
575-356-8082
Provider Enumeration Date:
11/15/2017