Provider First Line Business Practice Location Address:
6234 FOUNTAIN AVE
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:
90028-8214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-465-1111
Provider Business Practice Location Address Fax Number:
323-465-5317
Provider Enumeration Date:
06/08/2006