Provider First Line Business Practice Location Address: 
2811 EMERALD LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LANCASTER
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93535-6182
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-794-3559
    Provider Business Practice Location Address Fax Number: 
661-494-8464
    Provider Enumeration Date: 
09/22/2016