Provider First Line Business Practice Location Address: 
8181 BOLSA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MIDWAY CITY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92655
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-698-8181
    Provider Business Practice Location Address Fax Number: 
714-698-1609
    Provider Enumeration Date: 
12/14/2007