Provider First Line Business Practice Location Address:
72345 HIGHWAY 111
Provider Second Line Business Practice Location Address:
DESERT CROSSING SHOPPING CENTER
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-2746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-674-2121
Provider Business Practice Location Address Fax Number:
760-674-0555
Provider Enumeration Date:
03/15/2007