Provider First Line Business Practice Location Address: 
23550 LYONS AVE STE 211
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEWHALL
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91321
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-277-1848
    Provider Business Practice Location Address Fax Number: 
209-360-0090
    Provider Enumeration Date: 
07/19/2011