Provider First Line Business Practice Location Address:
96 OAK TREE WAY
Provider Second Line Business Practice Location Address:
BLDG 6
Provider Business Practice Location Address City Name:
MAMMOTH LAKES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-920-6574
Provider Business Practice Location Address Fax Number:
760-582-4559
Provider Enumeration Date:
09/18/2026