Provider First Line Business Practice Location Address:
452 OLD MAMMOTH RD.
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
MAMMOTH LAKES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-934-3730
Provider Business Practice Location Address Fax Number:
760-934-3732
Provider Enumeration Date:
08/14/2006