Provider First Line Business Practice Location Address:
4318 S MAIN 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:
90037-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-449-4040
Provider Business Practice Location Address Fax Number:
213-652-4156
Provider Enumeration Date:
10/21/2011