Provider First Line Business Practice Location Address:
145 E 124TH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-221-0555
Provider Business Practice Location Address Fax Number:
562-595-7977
Provider Enumeration Date:
02/19/2019