Provider First Line Business Practice Location Address:
1714 IVAR AVE # D
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:
90028-5124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-471-3212
Provider Business Practice Location Address Fax Number:
323-464-9161
Provider Enumeration Date:
09/13/2023