Provider First Line Business Practice Location Address: 
2942 N 7TH AVE
    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: 
85013-4179
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
623-907-0746
    Provider Business Practice Location Address Fax Number: 
623-907-0756
    Provider Enumeration Date: 
02/27/2018