Provider First Line Business Practice Location Address: 
4910 N 44TH ST
    Provider Second Line Business Practice Location Address: 
SUITE 10
    Provider Business Practice Location Address City Name: 
PHOENIX
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85018-2730
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
602-840-3636
    Provider Business Practice Location Address Fax Number: 
602-840-7403
    Provider Enumeration Date: 
04/30/2006