Provider First Line Business Practice Location Address:
225 E CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCUMCARI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88401-2214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-461-2558
Provider Business Practice Location Address Fax Number:
505-461-2561
Provider Enumeration Date:
11/14/2006