Provider First Line Business Practice Location Address:
98 STATE HWY 150
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
EL PRADO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-225-3020
Provider Business Practice Location Address Fax Number:
505-212-5265
Provider Enumeration Date:
04/24/2026