Provider First Line Business Practice Location Address:
614 E HYDE PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90302-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-777-1727
Provider Business Practice Location Address Fax Number:
424-777-1737
Provider Enumeration Date:
02/18/2026