Provider First Line Business Practice Location Address:
963 WEST AVENUE J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-224-9310
Provider Business Practice Location Address Fax Number:
800-516-1658
Provider Enumeration Date:
05/16/2010