Provider First Line Business Practice Location Address:
8646 S 14TH ST
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:
85042-7902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-243-5491
Provider Business Practice Location Address Fax Number:
602-243-5486
Provider Enumeration Date:
12/19/2006