Provider First Line Business Practice Location Address:
5519 S CENTINELA AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90066-6945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-301-9121
Provider Business Practice Location Address Fax Number:
310-390-8578
Provider Enumeration Date:
08/28/2012