Provider First Line Business Practice Location Address:
1046 E 4TH 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:
90802-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-432-7468
Provider Business Practice Location Address Fax Number:
562-432-1425
Provider Enumeration Date:
07/24/2015