Provider First Line Business Practice Location Address:
1679 ADAMS 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:
92243-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-569-0047
Provider Business Practice Location Address Fax Number:
619-334-6251
Provider Enumeration Date:
10/28/2019