Provider First Line Business Practice Location Address:
100 E. SECOND STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-355-2858
Provider Business Practice Location Address Fax Number:
760-355-4550
Provider Enumeration Date:
09/13/2006