Provider First Line Business Practice Location Address:
1936 N KENMORE AVE
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:
90027-1812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
346-273-9123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2025