Provider First Line Business Practice Location Address: 
8439 SAN MIGUEL AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SOUTH GATE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90280-2524
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-428-2458
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/20/2015