Provider First Line Business Practice Location Address: 
6343 EASTERN AVE STE B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BELL GARDENS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90201-1605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-562-4891
    Provider Business Practice Location Address Fax Number: 
323-562-4898
    Provider Enumeration Date: 
07/03/2007