Provider First Line Business Practice Location Address:
1059 S HOLT 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:
90035-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-657-5678
Provider Business Practice Location Address Fax Number:
310-652-5369
Provider Enumeration Date:
09/13/2005