Provider First Line Business Practice Location Address:
BLDG 3005
Provider Second Line Business Practice Location Address:
S R 108
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-932-1614
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2006