Provider First Line Business Practice Location Address:
128 N LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-742-6088
Provider Business Practice Location Address Fax Number:
310-742-6456
Provider Enumeration Date:
05/01/2007