Provider First Line Business Practice Location Address: 
600 E OCEAN BLVD STE 400B
    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: 
90802-5013
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-310-9741
    Provider Business Practice Location Address Fax Number: 
888-746-6008
    Provider Enumeration Date: 
12/10/2014