Provider First Line Business Practice Location Address:
5901 W INDIAN SCHOOL RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85033-2824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-846-1403
Provider Business Practice Location Address Fax Number:
623-247-6345
Provider Enumeration Date:
09/27/2005