Provider First Line Business Practice Location Address:
1463 S 4TH ST
Provider Second Line Business Practice Location Address:
STE 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:
92243-4749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-791-1936
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2010