Provider First Line Business Practice Location Address:
1539 BAXTER 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:
90026-1961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-520-2064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2012