Provider First Line Business Practice Location Address:
1073 ROSS AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-336-0703
Provider Business Practice Location Address Fax Number:
760-336-0734
Provider Enumeration Date:
08/10/2006