Provider First Line Business Practice Location Address:
420 S MANHATTAN PL APT 10
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:
90020-4186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-587-1336
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2014