Provider First Line Business Practice Location Address:
632 SOUTH CAMINO REAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92264-7617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-413-0725
Provider Business Practice Location Address Fax Number:
518-684-8526
Provider Enumeration Date:
06/22/2005