Provider First Line Business Practice Location Address: 
3865 E LOHMAN AVE
    Provider Second Line Business Practice Location Address: 
SUITE 3
    Provider Business Practice Location Address City Name: 
LAS CRUCES
    Provider Business Practice Location Address State Name: 
NM
    Provider Business Practice Location Address Postal Code: 
88011-8292
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
575-527-2600
    Provider Business Practice Location Address Fax Number: 
575-527-5342
    Provider Enumeration Date: 
10/24/2006