Provider First Line Business Practice Location Address:
506 W ATEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IMPERIAL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92251-9718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-352-3505
Provider Business Practice Location Address Fax Number:
760-545-0186
Provider Enumeration Date:
09/21/2005