Provider First Line Business Practice Location Address:
222 S SUMMIT AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-445-0582
Provider Business Practice Location Address Fax Number:
928-443-0974
Provider Enumeration Date:
04/28/2006