Provider First Line Business Practice Location Address:
4430 FOUNTAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-2005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-663-8411
Provider Business Practice Location Address Fax Number:
323-663-8455
Provider Enumeration Date:
05/20/2011