Provider First Line Business Practice Location Address: 
19671 BEACH BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 400
    Provider Business Practice Location Address City Name: 
HUNTINGTON BEACH
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92648-5901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-842-0651
    Provider Business Practice Location Address Fax Number: 
714-848-7826
    Provider Enumeration Date: 
04/24/2006