Provider First Line Business Practice Location Address: 
52040 AVENIDA DIAZ
    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: 
92253-3226
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-404-5743
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/27/2015