Provider First Line Business Practice Location Address:
655 MAPLE AVE
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:
90014-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-524-2829
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2025