Provider First Line Business Practice Location Address:
4011 W JEFFERSON BLVD FL 2
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:
90016-4122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-860-4491
Provider Business Practice Location Address Fax Number:
213-262-2920
Provider Enumeration Date:
11/21/2025