Provider First Line Business Practice Location Address:
57463 TWENTYNINE PALMS HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-2331
Provider Business Practice Location Address Fax Number:
760-365-1811
Provider Enumeration Date:
06/13/2005