Provider First Line Business Practice Location Address: 
4201 LONG BEACH BLVD
    Provider Second Line Business Practice Location Address: 
400
    Provider Business Practice Location Address City Name: 
LONG BEACH
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90807-2007
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-472-0158
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/10/2015