Provider First Line Business Practice Location Address:
1104 N MISSION RD
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:
90033-1017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-343-0520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2016