Provider First Line Business Practice Location Address:
4352 FOUNTAIN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
L A
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-913-9094
Provider Business Practice Location Address Fax Number:
323-913-2492
Provider Enumeration Date:
09/06/2006