Provider First Line Business Practice Location Address:
1930 E ANAHEIM ST
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:
90813-3908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-478-4102
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2026