Provider First Line Business Practice Location Address: 
2610 INDUSTRY WAY BLVD., SUITE C
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LYNWOOD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90262-4283
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
213-385-5100
    Provider Business Practice Location Address Fax Number: 
213-260-7791
    Provider Enumeration Date: 
06/06/2012