Provider First Line Business Practice Location Address:
1552 W 139TH ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90249-2642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-324-0516
Provider Business Practice Location Address Fax Number:
310-324-0518
Provider Enumeration Date:
08/24/2006