Provider First Line Business Practice Location Address: 
680 E DEUCE OF CLUBS
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
SHOW LOW
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
85901-4827
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
928-537-9300
    Provider Business Practice Location Address Fax Number: 
928-537-0183
    Provider Enumeration Date: 
07/26/2006