Provider First Line Business Practice Location Address:
1375 MIDVALE AVE
Provider Second Line Business Practice Location Address:
#306
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90024-5495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-312-9977
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006