Provider First Line Business Practice Location Address: 
1353 E 3RD ST
    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: 
90802-3671
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-739-8583
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/30/2024