Provider First Line Business Practice Location Address: 
815 N LA BREA AVE
    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: 
90038-3340
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-933-3744
    Provider Business Practice Location Address Fax Number: 
323-933-3854
    Provider Enumeration Date: 
12/05/2006