Provider First Line Business Practice Location Address: 
17010 APPLE AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HURON
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93234
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-945-7433
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/01/2019