Provider First Line Business Practice Location Address: 
1151 S 4TH ST STE G
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EL CENTRO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92243-4741
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-557-8880
    Provider Business Practice Location Address Fax Number: 
760-557-8881
    Provider Enumeration Date: 
10/10/2024