Provider First Line Business Practice Location Address:
247 ROSWELL AVE
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:
90803-1536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-656-2892
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2026