Provider First Line Business Practice Location Address:
126 OLD MAMMOTH RD
Provider Second Line Business Practice Location Address:
SUITE 214
Provider Business Practice Location Address City Name:
MAMMOTH LAKES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-924-8503
Provider Business Practice Location Address Fax Number:
760-924-0541
Provider Enumeration Date:
09/21/2006