Provider First Line Business Practice Location Address: 
3877 N 7TH ST
    Provider Second Line Business Practice Location Address: 
SUITE 400
    Provider Business Practice Location Address City Name: 
PHOENIX
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85014-5072
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
602-257-8118
    Provider Business Practice Location Address Fax Number: 
602-528-0099
    Provider Enumeration Date: 
04/11/2006