Provider First Line Business Practice Location Address:
3 MI S OF PAGE ON NR-20 COPPERMINE RD
Provider Second Line Business Practice Location Address:
KAIBETO CHAPTER HOUSE
Provider Business Practice Location Address City Name:
LECHEE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-283-2501
Provider Business Practice Location Address Fax Number:
928-283-2677
Provider Enumeration Date:
10/18/2012