Provider First Line Business Practice Location Address:
32770 OLD WOMAN SPRINGS RD.
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LUCERNE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92356-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-248-6612
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2009