Provider First Line Business Practice Location Address:
1530 S WATERMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-1436
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2007