Provider First Line Business Practice Location Address:
1503 NORTH IMPERIAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 105-B
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-337-4100
Provider Business Practice Location Address Fax Number:
760-545-0255
Provider Enumeration Date:
04/11/2016