Provider First Line Business Practice Location Address:
1408 3/4 N AVENUE 47
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:
90042-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-246-5173
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2021