Provider First Line Business Practice Location Address:
2064 W AVENUE J
Provider Second Line Business Practice Location Address:
SUITE 385
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93536-5913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-435-1058
Provider Business Practice Location Address Fax Number:
661-793-7480
Provider Enumeration Date:
10/23/2006