Provider First Line Business Practice Location Address:
PA PROGRAM 1730 E. 120TH 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:
90059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-732-1090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2023