Provider First Line Business Practice Location Address:
1100 N STATE STREET
Provider Second Line Business Practice Location Address:
CLINIC TOWER A6A231A
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-409-7788
Provider Business Practice Location Address Fax Number:
323-441-7298
Provider Enumeration Date:
07/24/2017