Provider First Line Business Practice Location Address:
6333 W 3RD ST
Provider Second Line Business Practice Location Address:
STALL 708
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90036-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-936-5140
Provider Business Practice Location Address Fax Number:
323-936-5153
Provider Enumeration Date:
03/08/2012