Provider First Line Business Practice Location Address: 
6101 S RURAL RD
    Provider Second Line Business Practice Location Address: 
STE 102
    Provider Business Practice Location Address City Name: 
TEMPE
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85283-2910
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
480-878-5224
    Provider Business Practice Location Address Fax Number: 
480-427-3922
    Provider Enumeration Date: 
08/18/2014