Provider First Line Business Practice Location Address: 
1053 COLORADO BLVD
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
LOS ANGELES
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90041-2572
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-257-9361
    Provider Business Practice Location Address Fax Number: 
323-257-0509
    Provider Enumeration Date: 
09/20/2006