Provider First Line Business Practice Location Address:
1590 S IMPERIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
442-239-4478
Provider Business Practice Location Address Fax Number:
760-545-0034
Provider Enumeration Date:
02/01/2022