Provider First Line Business Practice Location Address:
4718 FOUNTAIN AVE
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-1766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-661-2097
Provider Business Practice Location Address Fax Number:
323-903-0338
Provider Enumeration Date:
08/05/2008