Provider First Line Business Practice Location Address:
1647 S HAYWORTH 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:
90035-4513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-659-7800
Provider Business Practice Location Address Fax Number:
833-392-1146
Provider Enumeration Date:
06/21/2007