Provider First Line Business Practice Location Address:
993 N BROADWAY STE A
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:
90012-1764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-625-7995
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2014