Provider First Line Business Practice Location Address:
240 1/2 EAST 109TH PLACE
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:
90061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-216-3850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2026