Provider First Line Business Practice Location Address:
4618 FOUNTAIN 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:
90029-1830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-953-7170
Provider Business Practice Location Address Fax Number:
323-663-2379
Provider Enumeration Date:
02/17/2011