Provider First Line Business Practice Location Address:
1708 MERIDIAN AVE APT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91030-5505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-513-7232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2010