Provider First Line Business Practice Location Address:
1424 W 45TH 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:
90062-2040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-697-7381
Provider Business Practice Location Address Fax Number:
323-697-7381
Provider Enumeration Date:
04/25/2026