Provider First Line Business Practice Location Address:
1552 W 122ND 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:
90047-5311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-394-8064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/16/2025