Provider First Line Business Practice Location Address:
26 E BASELINE RD STE 142
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:
85042-6547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-268-8158
Provider Business Practice Location Address Fax Number:
602-268-8312
Provider Enumeration Date:
08/31/2006