Provider First Line Business Practice Location Address:
11981 MIDWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCERN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-248-6245
Provider Business Practice Location Address Fax Number:
760-247-7354
Provider Enumeration Date:
10/23/2006