Provider First Line Business Practice Location Address:
1745 S IMPERIAL AVE
Provider Second Line Business Practice Location Address:
STE 112
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-312-9817
Provider Business Practice Location Address Fax Number:
760-312-9824
Provider Enumeration Date:
02/05/2008