Provider First Line Business Practice Location Address: 
2250 W WHITTIER BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 200
    Provider Business Practice Location Address City Name: 
LA HABRA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90631-3403
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-690-1199
    Provider Business Practice Location Address Fax Number: 
562-690-3934
    Provider Enumeration Date: 
02/20/2007