Provider First Line Business Practice Location Address:
34636 W COUNTY LINE RD
Provider Second Line Business Practice Location Address:
STE 32
Provider Business Practice Location Address City Name:
YUCAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-795-9355
Provider Business Practice Location Address Fax Number:
909-795-9439
Provider Enumeration Date:
10/21/2005