Provider First Line Business Practice Location Address:
2057 W 64TH 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:
90047-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-365-9117
Provider Business Practice Location Address Fax Number:
323-570-0386
Provider Enumeration Date:
01/18/2013