Provider First Line Business Practice Location Address:
1229 E JACKSON ST
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:
90805-6124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-240-1569
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2026