Provider First Line Business Practice Location Address:
1529 WEST 82ND 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:
90047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-470-1204
Provider Business Practice Location Address Fax Number:
310-217-0545
Provider Enumeration Date:
11/01/2013