Provider First Line Business Practice Location Address:
663 MIDVALE AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90024-2337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-208-5182
Provider Business Practice Location Address Fax Number:
310-208-2003
Provider Enumeration Date:
01/23/2007