Provider First Line Business Practice Location Address:
5611 E VERNON ST
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:
90815-2048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-561-5294
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2021