Provider First Line Business Practice Location Address:
7128 PACIFIC BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HUNTINGTON PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90255-4776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-586-0144
Provider Business Practice Location Address Fax Number:
323-586-0629
Provider Enumeration Date:
08/07/2009