Provider First Line Business Practice Location Address:
4421 E 5TH ST UNIT D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90814-3086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-222-6636
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2026