Provider First Line Business Practice Location Address:
13400 EAST SHEA BOULEVARD
Provider Second Line Business Practice Location Address:
PROVIDER ENROLLMENT
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-301-6990
Provider Business Practice Location Address Fax Number:
480-301-8673
Provider Enumeration Date:
06/02/2011