Provider First Line Business Practice Location Address: 
4107 E LIVE OAK AVE., SUITE H
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARCADIA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
626-348-2239
    Provider Business Practice Location Address Fax Number: 
626-348-2141
    Provider Enumeration Date: 
02/01/2022