Provider First Line Business Practice Location Address:
4764 EDGEWOOD PL
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:
90019-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-245-0199
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2024