Provider First Line Business Practice Location Address: 
41253 12TH ST W STE B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PALMDALE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93551-1413
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-266-2604
    Provider Business Practice Location Address Fax Number: 
661-266-2119
    Provider Enumeration Date: 
07/20/2012