Provider First Line Business Practice Location Address:
57402 TWENTYNINE PALMS HIGHWAY #1
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-9228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-2520
Provider Business Practice Location Address Fax Number:
484-526-6546
Provider Enumeration Date:
10/10/2016