Provider First Line Business Practice Location Address:
44460 OLD HWY 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACUMBA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-766-4071
Provider Business Practice Location Address Fax Number:
619-766-4128
Provider Enumeration Date:
12/01/2006