Provider First Line Business Practice Location Address: 
10515 MCFADDEN AVE
    Provider Second Line Business Practice Location Address: 
SUITE 105
    Provider Business Practice Location Address City Name: 
GARDEN GROVE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92843-5301
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-775-7525
    Provider Business Practice Location Address Fax Number: 
714-775-7109
    Provider Enumeration Date: 
01/03/2007