Provider First Line Business Practice Location Address:
4115 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90712-1043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-408-1140
Provider Business Practice Location Address Fax Number:
562-408-1141
Provider Enumeration Date:
06/22/2021