Provider First Line Business Practice Location Address:
1373 W 29TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90007-3195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-643-4240
Provider Business Practice Location Address Fax Number:
323-643-4209
Provider Enumeration Date:
12/22/2014