Provider First Line Business Practice Location Address:
105 S PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-1969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-674-8345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007