Provider First Line Business Practice Location Address:
5032 INADALE 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:
90043-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-968-2364
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2023