Provider First Line Business Practice Location Address:
2105 BEVERLY BLVD
Provider Second Line Business Practice Location Address:
STE 217A
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-483-5430
Provider Business Practice Location Address Fax Number:
213-483-4151
Provider Enumeration Date:
12/29/2005