Provider First Line Business Practice Location Address:
16143 KOKANEE RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-1355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-242-9579
Provider Business Practice Location Address Fax Number:
760-242-2213
Provider Enumeration Date:
08/28/2006