Provider First Line Business Practice Location Address:
72210 HIGHWAY 111 STE E-1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-2782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
442-274-8123
Provider Business Practice Location Address Fax Number:
442-274-2011
Provider Enumeration Date:
08/28/2025