Provider First Line Business Practice Location Address: 
701 W AVENUE K
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LOVINGTON
    Provider Business Practice Location Address State Name: 
NM
    Provider Business Practice Location Address Postal Code: 
88260-5514
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
575-739-2230
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/14/2020