Provider First Line Business Practice Location Address:
1601 N IMPERIAL AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-6306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-592-4650
Provider Business Practice Location Address Fax Number:
760-592-4667
Provider Enumeration Date:
08/05/2011