Provider First Line Business Practice Location Address:
5220B SILVER MINE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310-2103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-380-3185
Provider Business Practice Location Address Fax Number:
760-380-6783
Provider Enumeration Date:
10/06/2006