Provider First Line Business Practice Location Address:
2051 MARENGO ST RM C5G100
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:
90033-1352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-409-4309
Provider Business Practice Location Address Fax Number:
323-441-7293
Provider Enumeration Date:
12/08/2022