Provider First Line Business Practice Location Address:
1272 1/2 N ARDMORE AVE
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:
90029-1412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-645-9226
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2022