Provider First Line Business Practice Location Address:
72724 29 PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
TWENTYNINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92277-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-367-5906
Provider Business Practice Location Address Fax Number:
760-367-5986
Provider Enumeration Date:
07/15/2013