Provider First Line Business Practice Location Address:
1289 S MARINA DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SALTON CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-394-4338
Provider Business Practice Location Address Fax Number:
760-394-4339
Provider Enumeration Date:
10/23/2006