Provider First Line Business Practice Location Address:
1142 N BEACHWOOD DR APT F
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:
90038-1840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-365-4465
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2026