Provider First Line Business Practice Location Address:
1055 RUTH ST
Provider Second Line Business Practice Location Address:
SUITE #8
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-445-8503
Provider Business Practice Location Address Fax Number:
928-445-3268
Provider Enumeration Date:
10/01/2007