Provider First Line Business Practice Location Address:
74059 HIGHWAY 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-4105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-340-2146
Provider Business Practice Location Address Fax Number:
760-340-2148
Provider Enumeration Date:
12/27/2019