Provider First Line Business Practice Location Address: 
6802 NIXON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKEWOOD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90713-2809
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-750-5222
    Provider Business Practice Location Address Fax Number: 
323-750-1245
    Provider Enumeration Date: 
08/19/2014