Provider First Line Business Practice Location Address:
1800 VINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90028-5250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-280-9635
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2015