Provider First Line Business Practice Location Address:
726 MALCOLM AVE
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:
90024-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-273-0413
Provider Business Practice Location Address Fax Number:
310-273-0452
Provider Enumeration Date:
11/21/2025