Provider First Line Business Practice Location Address:
4212 N. 16TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-200-5975
Provider Business Practice Location Address Fax Number:
602-200-5375
Provider Enumeration Date:
10/04/2006