Provider First Line Business Practice Location Address:
615 ELM AVE
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:
90802-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-435-7350
Provider Business Practice Location Address Fax Number:
562-435-4532
Provider Enumeration Date:
09/14/2012