Provider First Line Business Practice Location Address:
501 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCUMCARI
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88401-2861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-461-1670
Provider Business Practice Location Address Fax Number:
505-461-6404
Provider Enumeration Date:
08/15/2005