Provider First Line Business Practice Location Address:
1058 VINE ST
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:
90038-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-462-5580
Provider Business Practice Location Address Fax Number:
323-462-5581
Provider Enumeration Date:
08/01/2012