Provider First Line Business Practice Location Address: 
26701 CUMBERLAND RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BEAR VALLEY SPRINGS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93561-9616
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-821-0252
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/23/2006