Provider First Line Business Practice Location Address:
1170 BAKER ST STE H1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-791-3250
Provider Business Practice Location Address Fax Number:
949-791-3251
Provider Enumeration Date:
12/23/2008