Provider First Line Business Practice Location Address:
340 S LA FAYETTE PARK PL APT 211
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:
90057-1680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-249-4508
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2012