Provider First Line Business Practice Location Address:
1111 W INYOKERN RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGECREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93555-2370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-821-0775
Provider Business Practice Location Address Fax Number:
818-206-0379
Provider Enumeration Date:
09/11/2019