Provider First Line Business Practice Location Address:
12472 GREENE 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:
90066-6433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-442-1985
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2023