Provider First Line Business Practice Location Address:
352 NEWPORT AVE
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:
90814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-438-8103
Provider Business Practice Location Address Fax Number:
562-438-8103
Provider Enumeration Date:
08/29/2007