Provider First Line Business Practice Location Address:
5436 S. BROADWAY
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:
90037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-694-7206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2012