Provider First Line Business Practice Location Address:
5354 W 64TH 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:
90302-1042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-590-4537
Provider Business Practice Location Address Fax Number:
310-590-4538
Provider Enumeration Date:
05/25/2010