Provider First Line Business Practice Location Address:
15215 S 48TH ST
Provider Second Line Business Practice Location Address:
SUITE 136
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85044-9142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-704-8550
Provider Business Practice Location Address Fax Number:
480-704-0199
Provider Enumeration Date:
10/23/2006