Provider First Line Business Practice Location Address:
26501 AVENUE 140
Provider Second Line Business Practice Location Address:
PORTERVILLE DEVELOPMENTAL CENTER
Provider Business Practice Location Address City Name:
PORTERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93257-9109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-782-2644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2012