Provider First Line Business Practice Location Address: 
525 N GARFIELD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MONTEREY PARK
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91754-1202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
951-929-6260
    Provider Business Practice Location Address Fax Number: 
951-765-2855
    Provider Enumeration Date: 
02/10/2016