Provider First Line Business Practice Location Address:
660 WEST BAKER ST
Provider Second Line Business Practice Location Address:
STE 327
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-751-5170
Provider Business Practice Location Address Fax Number:
714-751-0134
Provider Enumeration Date:
11/13/2008