Provider First Line Business Practice Location Address:
2212 PLACENTIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92627-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-646-2271
Provider Business Practice Location Address Fax Number:
949-646-1211
Provider Enumeration Date:
07/31/2007