Provider First Line Business Practice Location Address:
1194 S LORENA 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:
90023-2928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-526-8189
Provider Business Practice Location Address Fax Number:
323-526-8314
Provider Enumeration Date:
08/17/2026