Provider First Line Business Practice Location Address:
4616 DE LONGPRE 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:
90027-6076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-361-4182
Provider Business Practice Location Address Fax Number:
323-644-2084
Provider Enumeration Date:
12/19/2011