Provider First Line Business Practice Location Address:
1202 HIGHWAY 60 BUILDING E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOCORRO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-835-8343
Provider Business Practice Location Address Fax Number:
575-835-3986
Provider Enumeration Date:
12/19/2005