Provider First Line Business Practice Location Address:
1138 S LA CIENEGA BLVD APT 21
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:
90035-2589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-636-9606
Provider Business Practice Location Address Fax Number:
818-636-9606
Provider Enumeration Date:
02/11/2026