Provider First Line Business Practice Location Address:
2808 W 85TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90305-1824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-655-8547
Provider Business Practice Location Address Fax Number:
424-702-4295
Provider Enumeration Date:
09/09/2026