Provider First Line Business Practice Location Address: 
2040 CAMFIELD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COMMERCE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90040-1502
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-558-7678
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/26/2014