Provider First Line Business Practice Location Address:
18112 OUTER HIGHWAY 18
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-946-2243
Provider Business Practice Location Address Fax Number:
866-734-9830
Provider Enumeration Date:
08/18/2006