Provider First Line Business Practice Location Address: 
846 W AVENUE K
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LANCASTER
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93534-6022
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-855-5685
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/25/2021