Provider First Line Business Practice Location Address:
5970 DALE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUENA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90621-2150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-659-4200
Provider Business Practice Location Address Fax Number:
760-856-5500
Provider Enumeration Date:
08/28/2026