Provider First Line Business Practice Location Address:
1100 NORTH STATE STREET
Provider Second Line Business Practice Location Address:
CLINIC TOWER A6E
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-409-6566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2020