Provider First Line Business Practice Location Address:
2215 W 15TH 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:
90006-4703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-656-8266
Provider Business Practice Location Address Fax Number:
866-910-2595
Provider Enumeration Date:
12/17/2021