Provider First Line Business Practice Location Address: 
2655 W. OLYMPIC BLVD.
    Provider Second Line Business Practice Location Address: 
SUITE 207
    Provider Business Practice Location Address City Name: 
LOS ANGELES
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
213-388-7887
    Provider Business Practice Location Address Fax Number: 
213-388-3504
    Provider Enumeration Date: 
06/06/2006