Provider First Line Business Practice Location Address:
1591 GRIFFIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWENTY NINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-830-7054
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2007