Provider First Line Business Practice Location Address:
4508 W MLK BLVD APT 22
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:
90016-6006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-783-5669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2026