Provider First Line Business Practice Location Address:
6641 CRENSHAW BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90043-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-409-0327
Provider Business Practice Location Address Fax Number:
866-722-6503
Provider Enumeration Date:
04/11/2013