Provider First Line Business Practice Location Address:
8766 EAST HWY 69
Provider Second Line Business Practice Location Address:
HUMBOLDT UNIFIED SCHOOL DISTRICT 22 DONNA THAXTON
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-759-4028
Provider Business Practice Location Address Fax Number:
928-759-4030
Provider Enumeration Date:
10/23/2007