Provider First Line Business Practice Location Address:
4173 2ND AVE
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:
90008-4041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-290-5054
Provider Business Practice Location Address Fax Number:
323-299-7160
Provider Enumeration Date:
01/17/2020