Provider First Line Business Practice Location Address:
47050 WASHINGTON ST
Provider Second Line Business Practice Location Address:
4202
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-2629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-564-7444
Provider Business Practice Location Address Fax Number:
760-564-7422
Provider Enumeration Date:
09/26/2006