Provider First Line Business Practice Location Address:
1620 N 48TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85008-7723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-345-2345
Provider Business Practice Location Address Fax Number:
866-587-2383
Provider Enumeration Date:
03/31/2010