Provider First Line Business Practice Location Address:
4TH & INNER LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-380-6292
Provider Business Practice Location Address Fax Number:
760-380-4213
Provider Enumeration Date:
10/25/2006