Provider First Line Business Practice Location Address:
1829 E FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
1829 E,FAIRMOUNT AVE
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-5903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-577-4419
Provider Business Practice Location Address Fax Number:
602-274-0452
Provider Enumeration Date:
09/22/2006