Provider First Line Business Practice Location Address:
1600 SOUTH IMPERIAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 4
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
442-325-9959
Provider Business Practice Location Address Fax Number:
760-355-9523
Provider Enumeration Date:
07/24/2010