Provider First Line Business Practice Location Address:
11643 CENTRALIA STREET
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:
90715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-488-7332
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2025