Provider First Line Business Practice Location Address: 
6200 WILSHIRE BLVD STE 1209
    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: 
90048-5813
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-937-0197
    Provider Business Practice Location Address Fax Number: 
323-937-1257
    Provider Enumeration Date: 
08/05/2006