Provider First Line Business Practice Location Address:
5100 E ANAHEIM RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90815-4215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-498-2354
Provider Business Practice Location Address Fax Number:
562-597-7594
Provider Enumeration Date:
09/29/2006