Provider First Line Business Practice Location Address:
1148 S MOTT 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:
90023-2122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-286-1675
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2026