Provider First Line Business Practice Location Address:
1230 N AVENUE 63
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:
90042-1412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-257-9850
Provider Business Practice Location Address Fax Number:
323-344-3602
Provider Enumeration Date:
08/08/2007