Provider First Line Business Practice Location Address: 
25078 PEACHLAND AVE
    Provider Second Line Business Practice Location Address: 
SUITE F
    Provider Business Practice Location Address City Name: 
NEWHALL
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91321-2533
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-253-4514
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/02/2006