Provider First Line Business Practice Location Address:
225 WAKE AVE SPC 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-9653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-554-6311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2026