Provider First Line Business Practice Location Address:
2285 THUMB BUTTE RD
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:
86305-7551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-442-1234
Provider Business Practice Location Address Fax Number:
928-442-1351
Provider Enumeration Date:
11/15/2005