Provider First Line Business Practice Location Address: 
638 W DUARTE RD STE 3
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARCADIA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91007-7671
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
626-688-7020
    Provider Business Practice Location Address Fax Number: 
626-226-5616
    Provider Enumeration Date: 
03/15/2018