Provider First Line Business Practice Location Address:
679 BAYWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IMPERIAL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92251-8915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-352-0500
Provider Business Practice Location Address Fax Number:
760-352-0579
Provider Enumeration Date:
04/08/2008