Provider First Line Business Practice Location Address:
2119 E SOUTHERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85282-7503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-831-1844
Provider Business Practice Location Address Fax Number:
480-383-2685
Provider Enumeration Date:
08/15/2005