Provider First Line Business Practice Location Address:
626 N AVENUE 54
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:
90042-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-506-1708
Provider Business Practice Location Address Fax Number:
323-506-1708
Provider Enumeration Date:
09/24/2026