Provider First Line Business Practice Location Address:
203 BALSAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGECREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93555-3822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-559-3148
Provider Business Practice Location Address Fax Number:
760-559-3148
Provider Enumeration Date:
03/02/2011