Provider First Line Business Practice Location Address:
173 S FORMOSA 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:
90036-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-723-3017
Provider Business Practice Location Address Fax Number:
916-314-9619
Provider Enumeration Date:
07/31/2023