Provider First Line Business Practice Location Address: 
2930 W IMPERIAL HWY
    Provider Second Line Business Practice Location Address: 
SUITE #316
    Provider Business Practice Location Address City Name: 
INGLEWOOD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90303-3143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-242-2222
    Provider Business Practice Location Address Fax Number: 
323-242-2440
    Provider Enumeration Date: 
06/19/2008