Provider First Line Business Practice Location Address:
1515 E BETHANY HOME ROAD
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:
85014-2496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-812-3080
Provider Business Practice Location Address Fax Number:
602-274-1168
Provider Enumeration Date:
08/25/2005