Provider First Line Business Practice Location Address:
9304 S BROADWAY
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:
90003-4044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-777-5853
Provider Business Practice Location Address Fax Number:
323-777-9465
Provider Enumeration Date:
03/18/2007