Provider First Line Business Practice Location Address:
1768 W 36TH PL
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:
90018-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-605-9555
Provider Business Practice Location Address Fax Number:
818-605-9555
Provider Enumeration Date:
12/05/2025