Provider First Line Business Practice Location Address:
1600 SOUTH IMPERIAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-339-2802
Provider Business Practice Location Address Fax Number:
760-355-9520
Provider Enumeration Date:
10/13/2015