Provider First Line Business Practice Location Address: 
11888 BARTLETT AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ADELANTO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92301-1709
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-530-9944
    Provider Business Practice Location Address Fax Number: 
760-530-9977
    Provider Enumeration Date: 
04/23/2018