Provider First Line Business Practice Location Address:
1224 W 40TH PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGLES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-293-1111
Provider Business Practice Location Address Fax Number:
866-639-1851
Provider Enumeration Date:
10/02/2025