Provider First Line Business Practice Location Address:
11328 S CENTRAL 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:
90059-1642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-569-4062
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2026