Provider First Line Business Practice Location Address:
17360 BROOKHURST ST
Provider Second Line Business Practice Location Address:
ATTN: CREDENTIALING DEPT.
Provider Business Practice Location Address City Name:
FOUNTAIN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92708-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-665-1797
Provider Business Practice Location Address Fax Number:
760-837-8956
Provider Enumeration Date:
04/24/2007