Provider First Line Business Practice Location Address:
1600 N IMPERIAL AVE STE 101
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:
92251-1399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-412-4420
Provider Business Practice Location Address Fax Number:
760-919-3188
Provider Enumeration Date:
09/29/2025