Provider First Line Business Practice Location Address:
234 E 112TH ST RM 54
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:
90061-2542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-831-0331
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2013