Provider First Line Business Practice Location Address:
47250 WASHINGTON ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-771-9437
Provider Business Practice Location Address Fax Number:
760-564-8581
Provider Enumeration Date:
02/21/2007