Provider First Line Business Practice Location Address: 
5604 LA PAZ 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: 
90803-4844
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-743-7800
    Provider Business Practice Location Address Fax Number: 
562-961-3529
    Provider Enumeration Date: 
02/25/2013