Provider First Line Business Practice Location Address: 
7275 W VINEYARD RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAVEEN
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85339-9805
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
602-605-8540
    Provider Business Practice Location Address Fax Number: 
602-605-8545
    Provider Enumeration Date: 
08/31/2011