Provider First Line Business Practice Location Address:
423 W 104TH 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:
90003-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-797-7854
Provider Business Practice Location Address Fax Number:
213-449-4554
Provider Enumeration Date:
12/31/2024