Provider First Line Business Practice Location Address: 
36915 COOK STREET STE 103
    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: 
92211
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-641-7217
    Provider Business Practice Location Address Fax Number: 
760-406-5636
    Provider Enumeration Date: 
09/12/2022