Provider First Line Business Practice Location Address:
5889 W 74TH ST
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:
90045-1721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-692-0740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2026