Provider First Line Business Practice Location Address:
15215 S 48TH STREET
Provider Second Line Business Practice Location Address:
SUITE #158
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85044-9139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-598-3006
Provider Business Practice Location Address Fax Number:
480-598-1184
Provider Enumeration Date:
05/03/2007