Provider First Line Business Practice Location Address:
4280 E BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYPOOL
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-473-2362
Provider Business Practice Location Address Fax Number:
928-473-2991
Provider Enumeration Date:
12/28/2005