Provider First Line Business Practice Location Address:
1500 S. AVE K.
Provider Second Line Business Practice Location Address:
STATION 3, SHROC
Provider Business Practice Location Address City Name:
PORTALES NM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
88130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-722-7315
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2018