Provider First Line Business Practice Location Address:
2412 W GREENWAY RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85023-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-588-7725
Provider Business Practice Location Address Fax Number:
602-588-7735
Provider Enumeration Date:
12/29/2006