Provider First Line Business Practice Location Address:
1404 CAMP BAKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97535-9604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-644-1812
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2024