Provider First Line Business Practice Location Address: 
27609 NUGGET DR
    Provider Second Line Business Practice Location Address: 
APARTMENT #4
    Provider Business Practice Location Address City Name: 
CANYON COUNTRY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91387-5831
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-625-4891
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/02/2014