Provider First Line Business Practice Location Address:
728 N RIDGEWOOD PL
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:
90038-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-490-0523
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2024