Provider First Line Business Practice Location Address:
12112 S VERMONT AVE APT 10
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:
90044-2974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-333-1713
Provider Business Practice Location Address Fax Number:
323-242-8951
Provider Enumeration Date:
12/11/2007