Provider First Line Business Practice Location Address:
58457 29 PALMS HWY
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-5879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-228-1813
Provider Business Practice Location Address Fax Number:
760-369-7331
Provider Enumeration Date:
05/27/2005