Provider First Line Business Practice Location Address:
2605 E 4TH 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:
90814-1205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-846-4142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2012