Provider First Line Business Practice Location Address:
1200 N STATE STREET CLINIC TOWER
Provider Second Line Business Practice Location Address:
SUITE A7D
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-1029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-409-7556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2021