Provider First Line Business Practice Location Address:
954 VINE STREET
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:
90038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-465-2828
Provider Business Practice Location Address Fax Number:
323-465-2830
Provider Enumeration Date:
10/31/2006