Provider First Line Business Practice Location Address:
57402 29 PALMS HWY
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-2520
Provider Business Practice Location Address Fax Number:
760-365-2524
Provider Enumeration Date:
09/30/2010