Provider First Line Business Practice Location Address:
UCLA 200 MEDICAL CENTER PLZ
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-794-0206
Provider Business Practice Location Address Fax Number:
310-794-0211
Provider Enumeration Date:
07/26/2007