Provider First Line Business Practice Location Address:
1507 N AVENUE 47
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:
90042-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-254-6991
Provider Business Practice Location Address Fax Number:
323-257-7458
Provider Enumeration Date:
02/02/2007