Provider First Line Business Practice Location Address:
1617 N GRAPE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMPTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90222-3507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-240-0996
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2026