Provider First Line Business Practice Location Address: 
4837 HUNTINGTON DR N
    Provider Second Line Business Practice Location Address: 
STE.8
    Provider Business Practice Location Address City Name: 
LOS ANGELES
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90032-1981
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-223-7200
    Provider Business Practice Location Address Fax Number: 
323-223-7500
    Provider Enumeration Date: 
03/10/2015