Provider First Line Business Practice Location Address:
2117 W 112TH 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:
90047-4746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-952-9895
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2025