Provider First Line Business Practice Location Address:
424 N GENESEE AVE STE 1
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:
90036-2245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-992-2893
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2023