Provider First Line Business Practice Location Address:
855 N FAIRFAX 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:
90046-7207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-653-1521
Provider Business Practice Location Address Fax Number:
323-653-1349
Provider Enumeration Date:
09/06/2005