Provider First Line Business Practice Location Address:
1300 NORTH 12TH STREET
Provider Second Line Business Practice Location Address:
SUITE 407
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-839-4915
Provider Business Practice Location Address Fax Number:
602-839-5112
Provider Enumeration Date:
06/12/2009