Provider First Line Business Practice Location Address:
1145 STURGIS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWENTY-NINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-830-2190
Provider Business Practice Location Address Fax Number:
586-439-5573
Provider Enumeration Date:
10/31/2017