Provider First Line Business Practice Location Address: 
5710 WINTER RIDGE DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAKERSFIELD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93313-2701
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-472-6706
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/01/2023