Provider First Line Business Practice Location Address: 
100 UCLA MEDICAL PLAZA SUITE 345
    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: 
90095-5232
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-208-5400
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/03/2015