Provider First Line Business Practice Location Address:
HIGHWAY 127
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOSHONE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92384-0158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-852-4383
Provider Business Practice Location Address Fax Number:
760-852-4304
Provider Enumeration Date:
08/18/2006