Provider First Line Business Practice Location Address:
301 N PRAIRIE AVE STE 110
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:
90301-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-672-7000
Provider Business Practice Location Address Fax Number:
310-672-7171
Provider Enumeration Date:
09/11/2025