Provider First Line Business Practice Location Address: 
409 PARK BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ORANGE COVE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93646-2439
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-626-4830
    Provider Business Practice Location Address Fax Number: 
559-626-7391
    Provider Enumeration Date: 
06/11/2011