Provider First Line Business Practice Location Address:
612 W E ST
Provider Second Line Business Practice Location Address:
WILMINGTON TEEN CENTER
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90744-5510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-204-2703
Provider Business Practice Location Address Fax Number:
310-626-9754
Provider Enumeration Date:
02/15/2011