Provider First Line Business Practice Location Address: 
130 W. ANAHEIM 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: 
90813
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-901-9999
    Provider Business Practice Location Address Fax Number: 
562-901-1120
    Provider Enumeration Date: 
10/08/2012