Provider First Line Business Practice Location Address: 
165 W HOSPITALITY LN
    Provider Second Line Business Practice Location Address: 
STE 1
    Provider Business Practice Location Address City Name: 
SAN BERNARDINO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92408-3334
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
909-885-0282
    Provider Business Practice Location Address Fax Number: 
909-889-7367
    Provider Enumeration Date: 
11/17/2006