Provider First Line Business Practice Location Address: 
69844 HIGHWAY 111
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RANCHO MIRAGE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92270-2849
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-318-4869
    Provider Business Practice Location Address Fax Number: 
760-320-2725
    Provider Enumeration Date: 
11/03/2005