Provider First Line Business Practice Location Address:
6102 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90003-1428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-236-7765
Provider Business Practice Location Address Fax Number:
661-722-6390
Provider Enumeration Date:
02/17/2010