Provider First Line Business Practice Location Address:
1815 W 36TH ST
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:
90018-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-456-1888
Provider Business Practice Location Address Fax Number:
323-803-7190
Provider Enumeration Date:
03/07/2025