Provider First Line Business Practice Location Address: 
81833 DOCTOR CARREON BLVD STE 5
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
INDIO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92201-5590
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-863-2241
    Provider Business Practice Location Address Fax Number: 
760-863-1919
    Provider Enumeration Date: 
10/16/2006