Provider First Line Business Practice Location Address:
598 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-352-3456
Provider Business Practice Location Address Fax Number:
760-312-9504
Provider Enumeration Date:
01/09/2006