Provider First Line Business Practice Location Address:
6211 1/2 TIPTON WAY
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:
90042-1361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-364-9693
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2026