Provider First Line Business Practice Location Address: 
3050 E LOHMAN AVE
    Provider Second Line Business Practice Location Address: 
SUITE F
    Provider Business Practice Location Address City Name: 
LAS CRUCES
    Provider Business Practice Location Address State Name: 
NM
    Provider Business Practice Location Address Postal Code: 
88011-8256
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
575-521-5970
    Provider Business Practice Location Address Fax Number: 
575-522-3095
    Provider Enumeration Date: 
12/09/2014