Provider First Line Business Practice Location Address:
1902 MARENGO ST STE 200A
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:
90033-1382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-276-6465
Provider Business Practice Location Address Fax Number:
323-276-8018
Provider Enumeration Date:
02/04/2025