Provider First Line Business Practice Location Address: 
12105 PARAMOUNT BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DOWNEY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90242-2309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-867-2796
    Provider Business Practice Location Address Fax Number: 
562-867-0738
    Provider Enumeration Date: 
08/30/2006