Provider First Line Business Practice Location Address: 
714 MESQUITE
    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: 
88401-4617
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
505-461-4434
    Provider Business Practice Location Address Fax Number: 
505-461-4435
    Provider Enumeration Date: 
11/30/2006