Provider First Line Business Practice Location Address:
78437 HIGHWAY 111
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:
760-564-1220
Provider Business Practice Location Address Fax Number:
760-340-2258
Provider Enumeration Date:
11/03/2006