Provider First Line Business Practice Location Address:
4007 PAIGE 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:
90031-1436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-734-2748
Provider Business Practice Location Address Fax Number:
818-926-2914
Provider Enumeration Date:
04/29/2026