Provider First Line Business Practice Location Address:
16130 KOKANEE RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-0833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-242-0762
Provider Business Practice Location Address Fax Number:
760-242-1803
Provider Enumeration Date:
07/09/2008