Provider First Line Business Practice Location Address:
2387 US HIGHWAY 86
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IMPERIAL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92251-9780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-5100
Provider Business Practice Location Address Fax Number:
760-353-0576
Provider Enumeration Date:
04/12/2007