Provider First Line Business Practice Location Address:
1828 E QUEENSDALE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMPTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90221-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-854-5743
Provider Business Practice Location Address Fax Number:
213-854-5743
Provider Enumeration Date:
10/22/2025