Provider First Line Business Practice Location Address: 
1945 PALO VERDE AVE
    Provider Second Line Business Practice Location Address: 
SUITE #101
    Provider Business Practice Location Address City Name: 
LONG BEACH
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90815-3443
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-596-6848
    Provider Business Practice Location Address Fax Number: 
562-596-8879
    Provider Enumeration Date: 
11/16/2006