Provider First Line Business Practice Location Address: 
41307 12TH ST W
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
PALMDALE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93551-1445
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-267-2021
    Provider Business Practice Location Address Fax Number: 
661-267-2664
    Provider Enumeration Date: 
05/23/2007