Provider First Line Business Practice Location Address: 
HWY191 HOSPITAL TURNOFF
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHINLE
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
86503-5748
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
928-674-7011
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/10/2012