Provider First Line Business Practice Location Address: 
637 W HILLSIDE AVE
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
PRESCOTT
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
86301-1909
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
800-994-3751
    Provider Business Practice Location Address Fax Number: 
800-994-3751
    Provider Enumeration Date: 
08/22/2014