Provider First Line Business Practice Location Address:
1224 VINE ST
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:
90038-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-769-6116
Provider Business Practice Location Address Fax Number:
818-990-2949
Provider Enumeration Date:
10/27/2006