Provider First Line Business Practice Location Address:
1632 ELLSMERE 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:
90019-3826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-533-5228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2026