Provider First Line Business Practice Location Address:
269 S LA FAYETTE PARK PL APT 449
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:
90057-1378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-604-0081
Provider Business Practice Location Address Fax Number:
714-522-8775
Provider Enumeration Date:
03/23/2009