Provider First Line Business Practice Location Address:
28200 HIGHWAY 189
Provider Second Line Business Practice Location Address:
BLDG R-110
Provider Business Practice Location Address City Name:
LAKE ARROWHEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92352-9700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-867-9083
Provider Business Practice Location Address Fax Number:
909-867-9086
Provider Enumeration Date:
04/25/2012