Provider First Line Business Practice Location Address: 
74-040 HIGHWAY III
    Provider Second Line Business Practice Location Address: 
SUITE L-202
    Provider Business Practice Location Address City Name: 
PALM DESERT
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92260
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-861-7275
    Provider Business Practice Location Address Fax Number: 
760-328-2186
    Provider Enumeration Date: 
10/01/2019