Provider First Line Business Practice Location Address: 
105 E MEADOW LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BIG BEAR CITY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92314-9410
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-847-6713
    Provider Business Practice Location Address Fax Number: 
833-563-2266
    Provider Enumeration Date: 
05/31/2022