Provider First Line Business Practice Location Address:
2051 MARENGO ST CLINIC TOWER SUITE A7D
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:
90089-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-389-7567
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2025