Provider First Line Business Practice Location Address:
945 MANNING AVENUE
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:
90024-3218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-927-7132
Provider Business Practice Location Address Fax Number:
910-776-7479
Provider Enumeration Date:
02/21/2012