Provider First Line Business Practice Location Address:
3629 MILE MARKER 34 NAVAJO ROUTE 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT DEFIANCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86504-0793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-729-2085
Provider Business Practice Location Address Fax Number:
928-729-2050
Provider Enumeration Date:
06/18/2008