Provider First Line Business Practice Location Address:
2747 W SOUTHERN AVE
Provider Second Line Business Practice Location Address:
SUIT 2A
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85282-4249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-454-9040
Provider Business Practice Location Address Fax Number:
602-431-0290
Provider Enumeration Date:
10/20/2005