Provider First Line Business Practice Location Address:
2263 N LAKEWOOD BLVD
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:
90815-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-375-1113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2026