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