Provider First Line Business Practice Location Address:
439 W 97TH 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:
90003-3968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-241-0558
Provider Business Practice Location Address Fax Number:
213-241-8458
Provider Enumeration Date:
06/30/2005