Provider First Line Business Practice Location Address: 
28237 NEWHALL RANCH RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VALENCIA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91355-0986
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-257-4242
    Provider Business Practice Location Address Fax Number: 
661-294-0020
    Provider Enumeration Date: 
02/06/2007