Provider First Line Business Practice Location Address:
2040 W BETHANY HOME RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015-2445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-248-0224
Provider Business Practice Location Address Fax Number:
602-248-0235
Provider Enumeration Date:
10/19/2006