Provider First Line Business Practice Location Address: 
2600 REDONDO AVE
    Provider Second Line Business Practice Location Address: 
SUITE 400
    Provider Business Practice Location Address City Name: 
LONG BEACH
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90806-2329
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-997-7888
    Provider Business Practice Location Address Fax Number: 
562-997-8884
    Provider Enumeration Date: 
04/14/2006