Provider First Line Business Practice Location Address:
144 SO ANITA AVE
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:
90049-3802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-472-8136
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2006