Provider First Line Business Practice Location Address:
2313 W YUMA 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:
85009-6441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-258-1542
Provider Business Practice Location Address Fax Number:
602-258-2318
Provider Enumeration Date:
07/30/2006