Provider First Line Business Practice Location Address: 
167 N MAIN STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TUBA CITY
    Provider Business Practice Location Address State Name: 
AZ
    Provider Business Practice Location Address Postal Code: 
86045
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-318-7475
    Provider Business Practice Location Address Fax Number: 
866-667-3006
    Provider Enumeration Date: 
07/07/2009