Provider First Line Business Practice Location Address: 
7023 HIGHWAY 54 70
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALAMOGORDO
    Provider Business Practice Location Address State Name: 
NM
    Provider Business Practice Location Address Postal Code: 
88310-9138
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
575-434-3783
    Provider Business Practice Location Address Fax Number: 
575-437-9222
    Provider Enumeration Date: 
01/03/2018