Provider First Line Business Practice Location Address:
790 W ORANGE AVE STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-3274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-8858
Provider Business Practice Location Address Fax Number:
760-545-0248
Provider Enumeration Date:
08/31/2006