Provider First Line Business Practice Location Address:
1462 VINE 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:
90028-8146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-461-9355
Provider Business Practice Location Address Fax Number:
323-461-7257
Provider Enumeration Date:
08/10/2006