Provider First Line Business Practice Location Address: 
49305 HIGHWAY 74 SPC 33
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PALM DESERT
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92260-6204
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-387-8503
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/24/2018