Provider First Line Business Practice Location Address:
166 INNER LOOP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-380-3144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2007