Provider First Line Business Practice Location Address:
1491 BAKER ST STE 1
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:
92626-3939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-545-3181
Provider Business Practice Location Address Fax Number:
714-545-0232
Provider Enumeration Date:
02/01/2007