Provider First Line Business Practice Location Address:
430S BURNSIDE #9A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-500-6139
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2010