Provider First Line Business Practice Location Address:
58471 29 PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-5818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-228-1766
Provider Business Practice Location Address Fax Number:
760-228-9830
Provider Enumeration Date:
08/30/2005