Provider First Line Business Practice Location Address:
1400 MIDVALE AVE
Provider Second Line Business Practice Location Address:
APT #217
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90024-5498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-602-9676
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2010