Provider First Line Business Practice Location Address: 
4566 FLORENCE AVE
    Provider Second Line Business Practice Location Address: 
#3
    Provider Business Practice Location Address City Name: 
CUDAHY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90201-4345
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-562-0055
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/16/2006