Provider First Line Business Practice Location Address:
1175 BAKER ST
Provider Second Line Business Practice Location Address:
E-16
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-979-1811
Provider Business Practice Location Address Fax Number:
714-979-2025
Provider Enumeration Date:
06/09/2011