Provider First Line Business Practice Location Address:
617 W MANCHESTER 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:
90044-5718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-750-7675
Provider Business Practice Location Address Fax Number:
888-534-5766
Provider Enumeration Date:
07/03/2012