Provider First Line Business Practice Location Address:
1200 N. STATE STREET
Provider Second Line Business Practice Location Address:
CLINIC TOWER, 2ND FLOOR, ROOM 2B300
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-409-6225
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2021