Provider First Line Business Practice Location Address:
12141 CENTRALIA ST UNIT 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90715-1515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-830-7848
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2026