Provider First Line Business Practice Location Address: 
11929 LOS NIETOS ROAD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SANTA FE SPRINGS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90670-2527
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-699-7200
    Provider Business Practice Location Address Fax Number: 
562-699-7210
    Provider Enumeration Date: 
10/03/2006