Provider First Line Business Practice Location Address:
5527 W. 119TH PLACE
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:
90304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-643-0153
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2019