Provider First Line Business Practice Location Address:
78822 HIGHWAY 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-564-7000
Provider Business Practice Location Address Fax Number:
760-564-0101
Provider Enumeration Date:
10/07/2008