Provider First Line Business Practice Location Address:
10833 LE CONTE AVE.
Provider Second Line Business Practice Location Address:
CHS 10-157
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-794-1929
Provider Business Practice Location Address Fax Number:
310-206-5302
Provider Enumeration Date:
10/23/2019