Provider First Line Business Practice Location Address:
437 OLD MAMMOTH ROAD
Provider Second Line Business Practice Location Address:
SUITE B3
Provider Business Practice Location Address City Name:
MAMMOTH LAKES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93546-9407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-934-0003
Provider Business Practice Location Address Fax Number:
855-243-3644
Provider Enumeration Date:
01/19/2012