Provider First Line Business Practice Location Address: 
1314 S EUCLID ST
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
ANAHEIM
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92802-2079
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-776-4373
    Provider Business Practice Location Address Fax Number: 
714-776-4370
    Provider Enumeration Date: 
11/14/2006