Provider First Line Business Practice Location Address:
1041 W 76TH ST
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:
90044-2407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-394-5889
Provider Business Practice Location Address Fax Number:
213-723-2087
Provider Enumeration Date:
03/02/2022