Provider First Line Business Practice Location Address:
12610 S WESTERN 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:
90047-5252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-757-1853
Provider Business Practice Location Address Fax Number:
323-757-1281
Provider Enumeration Date:
10/07/2005