Provider First Line Business Practice Location Address:
1140 W 18TH ST
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:
90015-3326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-949-1716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2026