Provider First Line Business Practice Location Address:
2409 E 1ST 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:
90033-3549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-363-5107
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2026