Provider First Line Business Practice Location Address:
74000 COUNTRY CLUB STE BL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-568-6900
Provider Business Practice Location Address Fax Number:
760-568-6914
Provider Enumeration Date:
04/17/2013