Provider First Line Business Practice Location Address:
5580 IMPERIAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH GATE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90280-7418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-401-0123
Provider Business Practice Location Address Fax Number:
562-803-9433
Provider Enumeration Date:
10/12/2007