Provider First Line Business Practice Location Address:
1119 DAWSON AVE APT 1
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:
90804-7242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-537-2765
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2018