Provider First Line Business Practice Location Address:
101 THE CITY DRIVE SOUTH
Provider Second Line Business Practice Location Address:
DOUGHLAS HOSPITAL, 3RD FLOOR, ROOM 3003
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-456-6411
Provider Business Practice Location Address Fax Number:
714-456-5149
Provider Enumeration Date:
04/24/2024