Provider First Line Business Practice Location Address: 
300 EL CAMINO REAL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SIERRA VISTA
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85635-2812
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
520-885-2231
    Provider Business Practice Location Address Fax Number: 
520-885-2471
    Provider Enumeration Date: 
10/12/2006