Provider First Line Business Practice Location Address: 
82900 AVENUE 42
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
INDIO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92203-9658
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-347-3524
    Provider Business Practice Location Address Fax Number: 
760-775-8372
    Provider Enumeration Date: 
08/25/2011