Provider First Line Business Practice Location Address:
117 N IMPERIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IMPERIAL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92251-1262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-355-2863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006