Provider First Line Business Practice Location Address:
980 W. 17TH STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92706-3554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-543-4629
Provider Business Practice Location Address Fax Number:
714-543-0306
Provider Enumeration Date:
01/23/2008