Provider First Line Business Practice Location Address:
715 W MARIPOSA ST
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:
85013-2449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-274-7318
Provider Business Practice Location Address Fax Number:
602-274-7549
Provider Enumeration Date:
02/25/2008