Provider First Line Business Practice Location Address: 
1522 E SOUTHERN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TEMPE
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85282-5689
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
602-808-2800
    Provider Business Practice Location Address Fax Number: 
602-808-2715
    Provider Enumeration Date: 
11/25/2014