Provider First Line Business Practice Location Address: 
4700 EASTON DR SUITE 10A & 10B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAKERFIELD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91352
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-843-7130
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/23/2022