Provider First Line Business Practice Location Address:
4722 N 24TH ST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-4800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-546-0676
Provider Business Practice Location Address Fax Number:
602-546-5012
Provider Enumeration Date:
08/22/2005