Provider First Line Business Practice Location Address:
1736 SO. SEPULVEDA BLVD.,
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-478-0248
Provider Business Practice Location Address Fax Number:
310-473-0650
Provider Enumeration Date:
12/20/2011