Provider First Line Business Practice Location Address:
1591 1/2 MANNING 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:
90024-5821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-431-9551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2019