Provider First Line Business Practice Location Address: 
7601 IMPERIAL HWY
    Provider Second Line Business Practice Location Address: 
RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
    Provider Business Practice Location Address City Name: 
DOWNEY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90242-3456
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-401-6319
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/03/2006