Provider First Line Business Practice Location Address:
1971 LUCILE 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:
90039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-367-2714
Provider Business Practice Location Address Fax Number:
323-663-0850
Provider Enumeration Date:
05/15/2006