Provider First Line Business Practice Location Address:
211 N 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:
90301-1412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-855-0556
Provider Business Practice Location Address Fax Number:
310-419-9475
Provider Enumeration Date:
04/01/2016