Provider First Line Business Practice Location Address:
19038 SOLEDAD CANYON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYON COUNTRY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91351-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-252-5192
Provider Business Practice Location Address Fax Number:
661-252-5193
Provider Enumeration Date:
05/16/2012