Provider First Line Business Practice Location Address:
STURGIS AVE AND 1ST STREET
Provider Second Line Business Practice Location Address:
MARINE CORPS AIR GROUND COMBAT CENTER
Provider Business Practice Location Address City Name:
TWENTYNINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-830-2070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2008