Provider First Line Business Practice Location Address: 
7128 PACIFIC BLVD
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
HUNTINGTON PARK
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90255-4776
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-586-0144
    Provider Business Practice Location Address Fax Number: 
323-586-0629
    Provider Enumeration Date: 
08/07/2009