Provider First Line Business Practice Location Address: 
1122 E BUCKEYE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PHOENIX
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85034-4020
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
602-705-7308
    Provider Business Practice Location Address Fax Number: 
602-252-2482
    Provider Enumeration Date: 
02/08/2018