Provider First Line Business Practice Location Address:
1526 IDYLWILD DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-2237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-442-1234
Provider Business Practice Location Address Fax Number:
928-442-1351
Provider Enumeration Date:
07/07/2005