Provider First Line Business Practice Location Address:
801 WEST MAPLE
Provider Second Line Business Practice Location Address:
SAN JUAN REGIONAL MEDICAL CENTER
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:
505-609-2451
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2011