Provider First Line Business Practice Location Address:
2612 IDELL ST STE 29
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:
90065-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-884-3918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2022