Provider First Line Business Practice Location Address:
500 HWY 89 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86313-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-445-4861
Provider Business Practice Location Address Fax Number:
928-776-6125
Provider Enumeration Date:
09/20/2006