Provider First Line Business Practice Location Address:
1410 N KENMORE AVE APT 5
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:
90027-5826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-512-9269
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2020