Provider First Line Business Practice Location Address:
19822 HAIDA ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307-5572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-810-7161
Provider Business Practice Location Address Fax Number:
760-810-7162
Provider Enumeration Date:
02/26/2009