Provider First Line Business Practice Location Address:
5436 S BROADWAY
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:
90037-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-234-6261
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2011