Provider First Line Business Practice Location Address:
500 N. HIGHWAY 89
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
180-094-9100
Provider Business Practice Location Address Fax Number:
928-776-6125
Provider Enumeration Date:
09/29/2006