Provider First Line Business Practice Location Address:
1548 GRANVILLE AVE
Provider Second Line Business Practice Location Address:
APT #5
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90025-2883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-210-6718
Provider Business Practice Location Address Fax Number:
310-826-7797
Provider Enumeration Date:
03/19/2010