Provider First Line Business Practice Location Address:
1463 S 4TH ST
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:
92243-4749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-881-4500
Provider Business Practice Location Address Fax Number:
619-291-6855
Provider Enumeration Date:
10/21/2014