Provider First Line Business Practice Location Address:
2223 E HIDALGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85040-5401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-844-2149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/14/2026