Provider First Line Business Practice Location Address: 
2537 SANDSTONE CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PALMDALE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93551-1515
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
213-984-0512
    Provider Business Practice Location Address Fax Number: 
661-441-5709
    Provider Enumeration Date: 
01/10/2015