Provider First Line Business Practice Location Address: 
1021 4TH ST STE B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TAFT
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93268-2433
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-765-7025
    Provider Business Practice Location Address Fax Number: 
661-765-7045
    Provider Enumeration Date: 
09/29/2010