Provider First Line Business Practice Location Address:
2359 SHOREDALE 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:
90031-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-259-2482
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2026