Provider First Line Business Practice Location Address:
1510 SAN PABLO ST
Provider Second Line Business Practice Location Address:
ROOM 514
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-5320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-442-7903
Provider Business Practice Location Address Fax Number:
323-442-7901
Provider Enumeration Date:
09/10/2009