Provider First Line Business Practice Location Address:
1745 S IMPERIAL AVE STE C
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:
92243-4252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-0488
Provider Business Practice Location Address Fax Number:
760-353-2796
Provider Enumeration Date:
11/27/2007