Provider First Line Business Practice Location Address:
1105 N. LONG 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:
90302-1437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-929-5519
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2009