Provider First Line Business Practice Location Address:
1429 N AVENUE 57
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:
90042-1927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-233-0676
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/03/2015