Provider First Line Business Practice Location Address:
29011 HOSPITAL RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-336-9715
Provider Business Practice Location Address Fax Number:
909-336-5751
Provider Enumeration Date:
10/25/2005