Provider First Line Business Practice Location Address:
2151 ROSS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-3685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-352-3505
Provider Business Practice Location Address Fax Number:
760-352-3046
Provider Enumeration Date:
05/29/2007