Provider First Line Business Practice Location Address:
4912 FOUNTAIN AVE
Provider Second Line Business Practice Location Address:
UNIT # B
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-664-6811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007