Provider First Line Business Practice Location Address: 
753 N MAIN ST
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
COTTONWOOD
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
86326-3649
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
928-634-7470
    Provider Business Practice Location Address Fax Number: 
928-639-3280
    Provider Enumeration Date: 
12/29/2005