Provider First Line Business Practice Location Address:
117 W HIGH 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:
88401-2809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-815-9224
Provider Business Practice Location Address Fax Number:
575-769-1735
Provider Enumeration Date:
08/25/2006