Provider First Line Business Practice Location Address:
NW CORNER OF NAVAJO RT. 12 & RT.7
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:
928-729-8328
Provider Business Practice Location Address Fax Number:
928-729-8348
Provider Enumeration Date:
12/02/2010