Provider First Line Business Practice Location Address:
1670 E 120 STREET
Provider Second Line Business Practice Location Address:
WEST SUPPORT BLDG #14 FL 2
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90059-3026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-201-4516
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2019