Provider First Line Business Practice Location Address:
1 CLINIC ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND CANYON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86023-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-638-2551
Provider Business Practice Location Address Fax Number:
928-638-2598
Provider Enumeration Date:
02/24/2011