Provider First Line Business Practice Location Address:
744 E 138TH 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:
90059-3532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-417-5404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2026