Provider First Line Business Practice Location Address:
3514 E SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-908-9338
Provider Business Practice Location Address Fax Number:
562-808-2145
Provider Enumeration Date:
08/01/2022