Provider First Line Business Practice Location Address:
603 WAKE AVE
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-776-0449
Provider Business Practice Location Address Fax Number:
760-353-4887
Provider Enumeration Date:
09/26/2008