Provider First Line Business Practice Location Address:
4701 W IMPERIAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90304-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-910-0660
Provider Business Practice Location Address Fax Number:
424-512-0206
Provider Enumeration Date:
08/13/2025