Provider First Line Business Practice Location Address:
1704 W MANCHESTER AVE
Provider Second Line Business Practice Location Address:
SUITE 207E
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90047-3077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-789-6100
Provider Business Practice Location Address Fax Number:
323-759-0440
Provider Enumeration Date:
08/30/2008