Provider First Line Business Practice Location Address: 
1201 S GARFIELD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALHAMBRA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91801-5037
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
626-457-1702
    Provider Business Practice Location Address Fax Number: 
626-457-1792
    Provider Enumeration Date: 
02/25/2013