Provider First Line Business Practice Location Address:
628 N VERMONT AVE
Provider Second Line Business Practice Location Address:
UNIT 4
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90004-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-805-0175
Provider Business Practice Location Address Fax Number:
323-668-2784
Provider Enumeration Date:
10/24/2006