Provider First Line Business Practice Location Address:
34501 SOUTH BLACK CANYON HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
BLACK CANYON CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-374-5658
Provider Business Practice Location Address Fax Number:
623-374-5233
Provider Enumeration Date:
11/06/2006