Provider First Line Business Practice Location Address: 
JCT. HWY 160 & NAVAJO ROUTE 25 - RED MESA
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TEEC NOS POS
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
86514
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
928-656-5000
    Provider Business Practice Location Address Fax Number: 
928-656-5164
    Provider Enumeration Date: 
07/06/2011