Provider First Line Business Practice Location Address:
800 N STATE COLLEGE BLVD
Provider Second Line Business Practice Location Address:
ATTN: KINESIOLOGY
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92831-3547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
657-278-7206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006