Provider First Line Business Practice Location Address: 
47-474 WASHINGTON ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LA QUINTA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92253
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
800-898-2020
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/26/2018