Provider First Line Business Practice Location Address:
638 S. VAN NESS AVE
Provider Second Line Business Practice Location Address:
UNIT 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:
90005-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-568-3988
Provider Business Practice Location Address Fax Number:
213-568-3988
Provider Enumeration Date:
12/18/2014