Provider First Line Business Practice Location Address:
1331 S CLARK RD BLDG 11
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:
92243-9516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-339-6425
Provider Business Practice Location Address Fax Number:
760-339-6436
Provider Enumeration Date:
01/23/2008