Provider First Line Business Practice Location Address:
132 S AVE 52
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:
90042-3914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-503-1495
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2025