Provider First Line Business Practice Location Address: 
600 N GARFIELD AVE
    Provider Second Line Business Practice Location Address: 
SUITE 111
    Provider Business Practice Location Address City Name: 
MONTEREY PARK
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91754-1166
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
626-280-3651
    Provider Business Practice Location Address Fax Number: 
626-280-3079
    Provider Enumeration Date: 
11/14/2006