Provider First Line Business Practice Location Address: 
10721 W INDIAN SCHOOL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AVONDALE
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85392-5636
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
623-772-7748
    Provider Business Practice Location Address Fax Number: 
623-772-7749
    Provider Enumeration Date: 
01/20/2017