Provider First Line Business Practice Location Address:
3700 ASHURST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWENTYNINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92277-9441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-431-1118
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2025