Provider First Line Business Practice Location Address:
161 OLD RANCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92211-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-341-3846
Provider Business Practice Location Address Fax Number:
760-341-3924
Provider Enumeration Date:
10/05/2007