Provider First Line Business Practice Location Address:
57475 TWENTYNINE PALMS HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-820-1742
Provider Business Practice Location Address Fax Number:
760-820-1752
Provider Enumeration Date:
07/18/2018