Provider First Line Business Practice Location Address:
570 W. 19TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92627-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-642-4222
Provider Business Practice Location Address Fax Number:
949-642-4855
Provider Enumeration Date:
02/26/2007