Provider First Line Business Practice Location Address:
10715 S PRAIRIE AVE
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:
90303-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-419-6463
Provider Business Practice Location Address Fax Number:
310-419-4678
Provider Enumeration Date:
09/03/2009