Provider First Line Business Practice Location Address:
29099 HOSPITAL ROAD
Provider Second Line Business Practice Location Address:
SUITE 204B
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-337-7771
Provider Business Practice Location Address Fax Number:
909-337-5353
Provider Enumeration Date:
10/08/2010