Provider First Line Business Practice Location Address:
390 OBISPO AVE APT 1
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:
90814-2508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-438-8707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2007