Provider First Line Business Practice Location Address:
648 E 21ST ST STE 102
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:
90011-1146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-275-1880
Provider Business Practice Location Address Fax Number:
213-275-1849
Provider Enumeration Date:
01/18/2018