Provider First Line Business Practice Location Address:
5412 S BROADWAY
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:
90037-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-789-0439
Provider Business Practice Location Address Fax Number:
323-325-7163
Provider Enumeration Date:
05/07/2019