Provider First Line Business Practice Location Address:
1540 ALCAZAR ST
Provider Second Line Business Practice Location Address:
CHP 155
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90089-9006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-442-2796
Provider Business Practice Location Address Fax Number:
323-442-1515
Provider Enumeration Date:
09/28/2011