Provider First Line Business Practice Location Address:
3820 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:
90029-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-664-0777
Provider Business Practice Location Address Fax Number:
323-664-0813
Provider Enumeration Date:
09/22/2006