Provider First Line Business Practice Location Address:
1093 S LUCERNE BLVD
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:
90019-6812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-400-8851
Provider Business Practice Location Address Fax Number:
414-296-8769
Provider Enumeration Date:
04/20/2015