Provider First Line Business Practice Location Address:
1601 W AVENUE J
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93534-2824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-945-1835
Provider Business Practice Location Address Fax Number:
661-945-2035
Provider Enumeration Date:
05/26/2010