Provider First Line Business Practice Location Address:
UNIVERSITY PARK MC0641
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:
90089-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-740-2679
Provider Business Practice Location Address Fax Number:
213-740-1265
Provider Enumeration Date:
03/28/2022