Provider First Line Business Practice Location Address:
19957 MODOC RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92308-6134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-308-5548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2026