Provider First Line Business Practice Location Address:
107 S 5TH ST
Provider Second Line Business Practice Location Address:
STE. 210
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-6151
Provider Business Practice Location Address Fax Number:
760-353-6152
Provider Enumeration Date:
12/09/2009