Provider First Line Business Practice Location Address:
5190 ATLANTIC AVE
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:
90805-6510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-428-4111
Provider Business Practice Location Address Fax Number:
562-984-5610
Provider Enumeration Date:
06/19/2018