Provider First Line Business Practice Location Address:
522 N LARCHMONT BLVD
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:
90004-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-973-7512
Provider Business Practice Location Address Fax Number:
213-608-0121
Provider Enumeration Date:
05/26/2025