Provider First Line Business Practice Location Address:
12424B MOUNT MESA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ISABELLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93240-9720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-379-5631
Provider Business Practice Location Address Fax Number:
760-379-2482
Provider Enumeration Date:
12/29/2005