Provider First Line Business Practice Location Address:
1141 E 16TH ST APT 3
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:
90813-2136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-977-0108
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2026