Provider First Line Business Practice Location Address:
1721 N BROADWAY
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:
90031-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-342-2808
Provider Business Practice Location Address Fax Number:
323-275-9233
Provider Enumeration Date:
07/23/2012