Provider First Line Business Practice Location Address:
1041 N EDGEMONT ST
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:
90029-2533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-665-4288
Provider Business Practice Location Address Fax Number:
323-665-7729
Provider Enumeration Date:
03/17/2009