Provider First Line Business Practice Location Address:
MWTC BLDG 3005 STATE ROUTE 108
Provider Second Line Business Practice Location Address:
ATTN: MEDICAL
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-932-1616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2008