Provider First Line Business Practice Location Address:
5439 CRENSHAW BLVD.
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-299-1869
Provider Business Practice Location Address Fax Number:
323-299-9043
Provider Enumeration Date:
08/16/2025