Provider First Line Business Practice Location Address:
29099 HOSPITAL RD.
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-337-0844
Provider Business Practice Location Address Fax Number:
909-337-0045
Provider Enumeration Date:
05/29/2007