Provider First Line Business Practice Location Address:
1121 W EDGEWARE RD
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:
90026-5168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-492-8053
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2026