Provider First Line Business Practice Location Address:
RR5 BOX 446
Provider Second Line Business Practice Location Address:
SANTA CLARA HEALTH CENTER
Provider Business Practice Location Address City Name:
ESPANOLA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87532-9614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-753-9421
Provider Business Practice Location Address Fax Number:
505-753-5039
Provider Enumeration Date:
04/24/2008