Provider First Line Business Practice Location Address:
375 E. BAKER STREET, SUITE A
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-361-6760
Provider Business Practice Location Address Fax Number:
714-361-6768
Provider Enumeration Date:
12/13/2013