Provider First Line Business Practice Location Address:
1503 N IMPERIAL AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-336-0010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2008