Provider First Line Business Practice Location Address:
NAVAJO ROUTE 12 MILE MARKER 34-3429
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:
86504-0885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-419-4672
Provider Business Practice Location Address Fax Number:
382-729-5338
Provider Enumeration Date:
07/01/2011