Provider First Line Business Practice Location Address:
1594 S IMPERIAL AVE
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:
92243-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-337-1025
Provider Business Practice Location Address Fax Number:
760-337-1011
Provider Enumeration Date:
06/26/2011