Provider First Line Business Practice Location Address: 
1750 E ARENAS RD
    Provider Second Line Business Practice Location Address: 
SUITE 21
    Provider Business Practice Location Address City Name: 
PALM SPRINGS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92262-7139
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-306-7676
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/03/2013