Provider First Line Business Practice Location Address: 
24303 WALNUT ST STE C1
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEWHALL
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91321-2900
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-410-6313
    Provider Business Practice Location Address Fax Number: 
732-782-0203
    Provider Enumeration Date: 
10/02/2023