Provider First Line Business Practice Location Address:
1665 SOUTH IMPERIAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-592-4783
Provider Business Practice Location Address Fax Number:
760-545-0256
Provider Enumeration Date:
11/27/2023