Provider First Line Business Practice Location Address:
1640 MARENGO ST
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:
90033-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-766-0563
Provider Business Practice Location Address Fax Number:
310-376-8620
Provider Enumeration Date:
03/26/2009