Provider First Line Business Practice Location Address:
5585 CHIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWENTYNINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92277-1329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-619-4108
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2026