Provider First Line Business Practice Location Address: 
78-060 CALLE ESTADO
    Provider Second Line Business Practice Location Address: 
NA
    Provider Business Practice Location Address City Name: 
LA QUINTA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92253-9225
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-698-9613
    Provider Business Practice Location Address Fax Number: 
760-564-0369
    Provider Enumeration Date: 
08/29/2022