Provider First Line Business Practice Location Address:
840 S IMPERIAL AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CALEXICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92231-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-768-3172
Provider Business Practice Location Address Fax Number:
760-768-1578
Provider Enumeration Date:
09/03/2009