Provider First Line Business Practice Location Address: 
1642 S PRIEST DR
    Provider Second Line Business Practice Location Address: 
BLDG 6, SUITE 101
    Provider Business Practice Location Address City Name: 
TEMPE
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85281-6204
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
480-929-5100
    Provider Business Practice Location Address Fax Number: 
602-302-7925
    Provider Enumeration Date: 
12/08/2015