Provider First Line Business Practice Location Address: 
8353 5TH ST
    Provider Second Line Business Practice Location Address: 
103
    Provider Business Practice Location Address City Name: 
DOWNEY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90241-3849
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-462-7070
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/26/2008