Provider First Line Business Practice Location Address: 
1009 LAUREL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SANTA PAULA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93060-1231
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
805-302-8577
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/27/2020