Provider First Line Business Practice Location Address:
5675 HISTORIC PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWENTYNINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92277-1742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-221-4580
Provider Business Practice Location Address Fax Number:
775-288-6378
Provider Enumeration Date:
05/30/2006