Provider First Line Business Practice Location Address:
9500 ETIWANDA AVE., WEST VALLEY DETENTION CENTER
Provider Second Line Business Practice Location Address:
ATTN: MEDICAL SRVCS/LIBERTY ROC
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-463-5115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2010