Provider First Line Business Practice Location Address:
12328 WASHINGTON PL
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90066-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-397-0857
Provider Business Practice Location Address Fax Number:
310-313-2020
Provider Enumeration Date:
04/20/2007