Provider First Line Business Practice Location Address:
4201 E CAMELBACK RD
Provider Second Line Business Practice Location Address:
UNIT 22
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85018-2743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-665-1869
Provider Business Practice Location Address Fax Number:
516-464-1972
Provider Enumeration Date:
07/18/2005