Provider First Line Business Practice Location Address:
2592 BASIL LANE
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:
90077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-681-3436
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2026