Provider First Line Business Practice Location Address:
5412 E VILLAGE RD
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:
90808-1698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-425-6434
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2025