Provider First Line Business Practice Location Address:
1177 E 54TH 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:
90011-4709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-283-5229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2013