Provider First Line Business Practice Location Address:
485 BROADWAY AVE STE F
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:
92243-2451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-970-4064
Provider Business Practice Location Address Fax Number:
619-304-1580
Provider Enumeration Date:
11/17/2025