Provider First Line Business Practice Location Address:
58457 TWENTYNINE PALMS HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 102A
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:
760-228-9657
Provider Business Practice Location Address Fax Number:
442-205-0060
Provider Enumeration Date:
10/21/2025