Provider First Line Business Practice Location Address: 
19720 BEACH BLVD
    Provider Second Line Business Practice Location Address: 
STE A
    Provider Business Practice Location Address City Name: 
HUNTINGTON BEACH
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92648-2987
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-593-1010
    Provider Business Practice Location Address Fax Number: 
714-593-2560
    Provider Enumeration Date: 
05/24/2007