Provider First Line Business Practice Location Address:
500 WALTER ST NE
Provider Second Line Business Practice Location Address:
P.T. DEPT, SUITE 310
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-727-8388
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2012