Individual
MAA VILI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2043 242ND ST, LOMITA, CA 90717-1115
(424) 263-4485
Mailing address
340 E 229TH PL, CARSON, CA 90745-4908
(310) 522-1064
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
N9429567
CA
Other
Enumeration date
01/15/2008
Last updated
01/15/2008
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