Provider First Line Business Practice Location Address:
137 PANAMINT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGECREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93555-3829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-375-6200
Provider Business Practice Location Address Fax Number:
760-375-3006
Provider Enumeration Date:
10/16/2005