Provider First Line Business Practice Location Address:
153 E. 110TH ST
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:
90061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-475-1126
Provider Business Practice Location Address Fax Number:
323-475-1132
Provider Enumeration Date:
02/05/2020