Provider First Line Business Practice Location Address: 
145 E DUARTE RD STE D
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARCADIA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91006-6691
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
626-317-5052
    Provider Business Practice Location Address Fax Number: 
626-317-5091
    Provider Enumeration Date: 
09/13/2011