Provider First Line Business Practice Location Address:
82204 US HIGHWAY 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92201-5630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-775-5552
Provider Business Practice Location Address Fax Number:
760-775-5002
Provider Enumeration Date:
01/29/2007