Provider First Line Business Practice Location Address:
528 S AVENUE 19 UNIT 6
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:
90031-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-241-9283
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2026