Provider First Line Business Practice Location Address:
152 E 111TH ST
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:
90061-2532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-563-0570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2026