Provider First Line Business Practice Location Address:
4701 W IMPERIAL HWY STE B
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:
90304-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-514-3631
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2025