Provider First Line Business Practice Location Address:
416 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:
90036-1717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-866-2020
Provider Business Practice Location Address Fax Number:
323-917-5032
Provider Enumeration Date:
07/21/2021