Provider First Line Business Practice Location Address: 
5204 SAND CASTLE CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAKERSFIELD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93312
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-829-7856
    Provider Business Practice Location Address Fax Number: 
661-829-7853
    Provider Enumeration Date: 
12/30/2014