Provider First Line Business Practice Location Address: 
HWY JUNCTION 371 AND ROUTE 9
    Provider Second Line Business Practice Location Address: 
CROWNPOINT HEALTHCARE FACILITY
    Provider Business Practice Location Address City Name: 
CROWNPOINT
    Provider Business Practice Location Address State Name: 
NM
    Provider Business Practice Location Address Postal Code: 
87313-0358
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
505-786-6283
    Provider Business Practice Location Address Fax Number: 
505-786-6394
    Provider Enumeration Date: 
09/26/2014