Provider First Line Business Practice Location Address: 
5 MILES NORTH OF FORT DEFIANCE ON RT 12
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT DEFIANCE
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
86504
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
505-593-0658
    Provider Business Practice Location Address Fax Number: 
928-729-5261
    Provider Enumeration Date: 
04/24/2013