Provider First Line Business Practice Location Address:
201 S 4TH AVE
Provider Second Line Business Practice Location Address:
INTAKE PROVIDER
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85003-2138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-876-9124
Provider Business Practice Location Address Fax Number:
602-253-3431
Provider Enumeration Date:
08/29/2012