Provider First Line Business Practice Location Address:
2650 ELM AVE
Provider Second Line Business Practice Location Address:
STE 218
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90806-1651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-705-1239
Provider Business Practice Location Address Fax Number:
818-705-0448
Provider Enumeration Date:
07/22/2006