Provider First Line Business Practice Location Address:
813 W BROADWAY ST UNIT B
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:
92363-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-266-4400
Provider Business Practice Location Address Fax Number:
760-266-4401
Provider Enumeration Date:
11/19/2018