Provider First Line Business Practice Location Address:
12380 4TH ST SPC 43
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUCAIPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92399-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-327-7803
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2026