Provider First Line Business Practice Location Address:
1212 E 3RD ST APT 2
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:
90802-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-435-4220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2007