Provider First Line Business Practice Location Address:
2315 W BETHANY HOME RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-249-2848
Provider Business Practice Location Address Fax Number:
602-249-6038
Provider Enumeration Date:
09/30/2005