Provider First Line Business Practice Location Address:
631A MAPLE 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:
90014-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-514-1456
Provider Business Practice Location Address Fax Number:
866-569-5017
Provider Enumeration Date:
10/31/2007