Provider First Line Business Practice Location Address:
35050 S OLD BLACK CANYON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK CANYON CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85324-9771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-374-5512
Provider Business Practice Location Address Fax Number:
623-374-5513
Provider Enumeration Date:
09/07/2005