Provider First Line Business Practice Location Address:
2139 S CLOVERDALE 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:
90016-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-422-0853
Provider Business Practice Location Address Fax Number:
323-372-3970
Provider Enumeration Date:
01/02/2022