Provider First Line Business Practice Location Address:
603 WAKE AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-919-2100
Provider Business Practice Location Address Fax Number:
760-301-9688
Provider Enumeration Date:
05/08/2026