Provider First Line Business Practice Location Address:
553 N MARIPOSA 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:
90004-2846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-900-5041
Provider Business Practice Location Address Fax Number:
760-560-1684
Provider Enumeration Date:
04/13/2022