Provider First Line Business Practice Location Address: 
9500 BRIMHALL RD
    Provider Second Line Business Practice Location Address: 
703
    Provider Business Practice Location Address City Name: 
BAKERSFIELD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93312-2241
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-829-6993
    Provider Business Practice Location Address Fax Number: 
661-829-6995
    Provider Enumeration Date: 
08/17/2011