Provider First Line Business Practice Location Address: 
7878 CRESCENT AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BUENA PARK
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90620-3950
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
714-226-0238
    Provider Business Practice Location Address Fax Number: 
714-226-0921
    Provider Enumeration Date: 
12/08/2011