Provider First Line Business Practice Location Address:
1200 N. BEAVER STREET
Provider Second Line Business Practice Location Address:
ATTN: PAYER CREDENTIALING
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-773-2546
Provider Business Practice Location Address Fax Number:
928-213-6292
Provider Enumeration Date:
11/09/2016