Provider First Line Business Practice Location Address:
1401 E 4TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90802-1869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-207-5564
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2011