Provider First Line Business Practice Location Address:
1530 BAKER STREET
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626-3752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-546-5170
Provider Business Practice Location Address Fax Number:
714-546-9411
Provider Enumeration Date:
10/04/2006