Provider First Line Business Practice Location Address: 
200 UCLA MEDICAL PLAZA
    Provider Second Line Business Practice Location Address: 
SUITE 420
    Provider Business Practice Location Address City Name: 
LOS ANGALES
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90095
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-206-0644
    Provider Business Practice Location Address Fax Number: 
310-825-3074
    Provider Enumeration Date: 
03/07/2008