Provider First Line Business Practice Location Address:
29101 HOSPITAL RD.
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352-1570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-336-3778
Provider Business Practice Location Address Fax Number:
909-336-0507
Provider Enumeration Date:
06/13/2006