Provider First Line Business Practice Location Address:
1107 W 83RD 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:
90044-3403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-659-7266
Provider Business Practice Location Address Fax Number:
213-659-7266
Provider Enumeration Date:
12/02/2025