Provider First Line Business Practice Location Address:
139 W. WHIPPLE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-776-1208
Provider Business Practice Location Address Fax Number:
928-541-9648
Provider Enumeration Date:
07/17/2006