Provider First Line Business Practice Location Address: 
1370 W SARAGOSA PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHANDLER
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85224-7216
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
480-250-4741
    Provider Business Practice Location Address Fax Number: 
480-840-1404
    Provider Enumeration Date: 
09/16/2006