Provider First Line Business Practice Location Address:
1401 BAILEY AVE BLDG A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEEDLES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92363-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
960-590-0155
Provider Business Practice Location Address Fax Number:
760-326-7170
Provider Enumeration Date:
10/19/2016