Provider First Line Business Practice Location Address:
4271 9TH AVE
Provider Second Line Business Practice Location Address:
APT 1
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-674-6287
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2025