Provider First Line Business Practice Location Address: 
15718 E GALE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HACIENDA HEIGHTS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91745
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
626-333-8512
    Provider Business Practice Location Address Fax Number: 
626-330-6766
    Provider Enumeration Date: 
12/27/2005