Provider First Line Business Practice Location Address:
14640 N TATUM BLVD #2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-992-9251
Provider Business Practice Location Address Fax Number:
602-992-1002
Provider Enumeration Date:
08/25/2006