Provider First Line Business Practice Location Address: 
1375 MIDVALE AVE
    Provider Second Line Business Practice Location Address: 
#306
    Provider Business Practice Location Address City Name: 
LOS ANGELES
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90024-5495
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-312-9977
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/30/2006