Provider First Line Business Practice Location Address:
56669 29 PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-5234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-3224
Provider Business Practice Location Address Fax Number:
760-365-8324
Provider Enumeration Date:
10/18/2011