Provider First Line Business Practice Location Address:
1919 E THOMAS RD
Provider Second Line Business Practice Location Address:
BLDG B 1ST FLOOR
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
602-933-0920
Provider Business Practice Location Address Fax Number:
602-933-2492
Provider Enumeration Date:
11/28/2006