Provider First Line Business Practice Location Address:
1147 E 88TH PL
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:
90002-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-440-3617
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2022