Provider First Line Business Practice Location Address:
5230 N. CLARK AVENUE
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90712-2649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-804-4428
Provider Business Practice Location Address Fax Number:
562-867-5264
Provider Enumeration Date:
12/29/2010