Provider First Line Business Practice Location Address:
200 MEDICAL PLZ
Provider Second Line Business Practice Location Address:
SUITE 430, BOX 956928
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-6928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-794-7274
Provider Business Practice Location Address Fax Number:
310-794-7436
Provider Enumeration Date:
02/03/2007