Provider First Line Business Practice Location Address:
16124 KASOTA RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-242-2099
Provider Business Practice Location Address Fax Number:
760-242-5065
Provider Enumeration Date:
10/19/2010