Provider First Line Business Practice Location Address:
3822 1/2 LIVE OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUDAHY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90201-4292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
572-489-6651
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2026