Provider First Line Business Practice Location Address:
200 MEDICAL PLAZA SUITE 365 B
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:
90095-3411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-7921
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2011