Provider First Line Business Practice Location Address:
2200 EAST 20TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-327-4872
Provider Business Practice Location Address Fax Number:
505-327-4915
Provider Enumeration Date:
12/01/2005