Provider First Line Business Practice Location Address:
1053 COLORADO BLVD
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:
90041-2572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-257-9361
Provider Business Practice Location Address Fax Number:
323-257-0509
Provider Enumeration Date:
09/20/2006