Provider First Line Business Practice Location Address: 
38745 TIERRA SUBIDA AVE
    Provider Second Line Business Practice Location Address: 
SUITE 150
    Provider Business Practice Location Address City Name: 
PALMDALE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93551-4540
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-272-9091
    Provider Business Practice Location Address Fax Number: 
661-272-4562
    Provider Enumeration Date: 
11/15/2006