Provider First Line Business Practice Location Address:
1709 W VERNON 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:
90062-1553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-298-1196
Provider Business Practice Location Address Fax Number:
323-298-1147
Provider Enumeration Date:
07/27/2006