Provider First Line Business Practice Location Address:
200 MEDICAL PLZ STE B265
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:
90095-9416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-9775
Provider Business Practice Location Address Fax Number:
310-794-1984
Provider Enumeration Date:
04/19/2012