Provider First Line Business Practice Location Address:
28011 STATE HWY 189
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352-2851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-336-3252
Provider Business Practice Location Address Fax Number:
909-336-3023
Provider Enumeration Date:
07/07/2006