Provider First Line Business Practice Location Address:
5631 S LA CIENEGA BLVD
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:
90056-1333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-613-1962
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2019