Provider First Line Business Practice Location Address:
12757 EDGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE VIEW
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35111-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-387-8856
Provider Business Practice Location Address Fax Number:
760-266-6144
Provider Enumeration Date:
06/27/2026