Provider First Line Business Practice Location Address:
12395 LEWIS ST STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92840-4698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-634-1125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2025