Provider First Line Business Practice Location Address:
1704 W.MANCHESTER AVE.
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90047-3057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-249-0112
Provider Business Practice Location Address Fax Number:
213-388-1017
Provider Enumeration Date:
06/28/2011